Provider Demographics
NPI:1891840203
Name:FOOT FIRST PODIATRY CL PC
Entity type:Organization
Organization Name:FOOT FIRST PODIATRY CL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:LEIB
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:815-477-9221
Mailing Address - Street 1:39 S VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-5826
Mailing Address - Country:US
Mailing Address - Phone:815-477-9221
Mailing Address - Fax:815-477-8916
Practice Address - Street 1:39 S VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-5826
Practice Address - Country:US
Practice Address - Phone:815-477-9221
Practice Address - Fax:815-477-8916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5619947OtherBC BS OF ILLINOIS
IL360620Medicare ID - Type UnspecifiedMEDICARE NUMBER
ILT34186Medicare UPIN