Provider Demographics
NPI:1386139145
Name:BARRIOS, EDGAR ALEXANDER (PEDORTHIST)
Entity type:Individual
Prefix:MR
First Name:EDGAR
Middle Name:ALEXANDER
Last Name:BARRIOS
Suffix:
Gender:M
Credentials:PEDORTHIST
Other - Prefix:MR
Other - First Name:ALEX
Other - Middle Name:
Other - Last Name:BARRIOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PEDORTHIST
Mailing Address - Street 1:702 JUSTINA ST
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-2425
Mailing Address - Country:US
Mailing Address - Phone:312-315-6584
Mailing Address - Fax:
Practice Address - Street 1:307 W SAINT PAUL ST
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:IL
Practice Address - Zip Code:61362-1860
Practice Address - Country:US
Practice Address - Phone:312-315-6584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-25
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL212000132224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212000132OtherILLINOIS LICENSE