Provider Demographics
NPI:1427148774
Name:ARDELL, ROBERT STEPHEN (DPM)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:STEPHEN
Last Name:ARDELL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-1903
Mailing Address - Country:US
Mailing Address - Phone:312-977-1179
Mailing Address - Fax:312-977-0425
Practice Address - Street 1:111 N WABASH AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-1903
Practice Address - Country:US
Practice Address - Phone:312-977-1179
Practice Address - Fax:312-977-0425
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-14
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-002682213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT36909Medicare UPIN