Provider Demographics
NPI:1447360896
Name:MERCADO FOOT & ANKLE CLINIC WEST LLC
Entity type:Organization
Organization Name:MERCADO FOOT & ANKLE CLINIC WEST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:O. KENT
Authorized Official - Middle Name:
Authorized Official - Last Name:MERCADO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:630-922-7722
Mailing Address - Street 1:24024 BRANCASTER DR
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-8044
Mailing Address - Country:US
Mailing Address - Phone:630-922-7722
Mailing Address - Fax:630-922-7727
Practice Address - Street 1:24024 BRANCASTER DR
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-8044
Practice Address - Country:US
Practice Address - Phone:630-922-7722
Practice Address - Fax:630-922-7727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004238213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5180850001OtherADMINASTAR DMERC #
IL016004238Medicaid
ILCI5229OtherRAILROAD MEDICARE GRP #
IL60001691OtherBC/BS PROVIDER #
IL016004238Medicaid