Provider Demographics
NPI:1487630406
Name:LIBERTYVILLE ANKLE & FOOT CLINIC, INC
Entity type:Organization
Organization Name:LIBERTYVILLE ANKLE & FOOT CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACOBSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:847-362-1320
Mailing Address - Street 1:1017 W PARK AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-2502
Mailing Address - Country:US
Mailing Address - Phone:847-362-1320
Mailing Address - Fax:847-362-1823
Practice Address - Street 1:1017 W PARK AVE
Practice Address - Street 2:SUITE A
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-2502
Practice Address - Country:US
Practice Address - Phone:847-362-1320
Practice Address - Fax:847-362-1823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-21
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-005031213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005031Medicaid
ILP00347050OtherRAILROAD MEDICARE
IL04932511OtherBLUECROSS
U90921Medicare UPIN
IL016005031Medicaid
IL213648Medicare PIN