Active NPI
Libertyville Ankle & Foot Clinic, Inc
- Foot & Ankle Surgery Podiatrist
- Libertyville, IL
National Provider Identifier
1487630406
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Foot & Ankle Surgery Podiatrist
- License
- 016-005031
- Legal business name
- LIBERTYVILLE ANKLE & FOOT CLINIC, INC
- Practice address
- 1017 W Park Ave
Suite a
Libertyville, IL 60048-2502 - Phone
- (847) 362-1320
- Fax
- (847) 362-1823
- NPI assigned
- Dec 21, 2005
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Scott A Jacobsen, DPM
- Title
- Owner
- Phone
- (847) 362-1320
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Foot & Ankle Surgery Podiatrist | 213ES0103X | 016-005031 | IL | Primary |
Addresses
Primary practice location
1017 W Park Ave
Suite a
Libertyville, IL 60048-2502
Mailing address
1017 W Park Ave
Suite a
Libertyville, IL 60048-2502
Phone (847) 362-1320
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 016005031 | Medicaid | IL | |
| P00347050 | Other | IL | RAILROAD MEDICARE |
| 04932511 | Other | IL | BLUECROSS |
National Provider Directory
National Provider DirectoryLocations
1017 W Park Ave
Ste A
Libertyville, IL 60048
Phone (847) 362-1320
Practitioners & affiliated clinicians
Practitioners 1
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1135123200000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1406246400000",
"number": "1487630406",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1017 W PARK AVE",
"address_2": "SUITE A",
"city": "LIBERTYVILLE",
"state": "IL",
"postal_code": "600482502",
"telephone_number": "847-362-1320",
"fax_number": "847-362-1823"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1017 W PARK AVE",
"address_2": "SUITE A",
"city": "LIBERTYVILLE",
"state": "IL",
"postal_code": "600482502",
"telephone_number": "847-362-1320",
"fax_number": "847-362-1823"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "LIBERTYVILLE ANKLE & FOOT CLINIC, INC",
"organizational_subpart": "NO",
"enumeration_date": "2005-12-21",
"last_updated": "2014-07-25",
"status": "A",
"authorized_official_last_name": "JACOBSEN",
"authorized_official_first_name": "SCOTT",
"authorized_official_middle_name": "A",
"authorized_official_title_or_position": "OWNER",
"authorized_official_telephone_number": "847-362-1320",
"authorized_official_credential": "DPM"
},
"taxonomies": [
{
"code": "213ES0103X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Podiatrist, Foot & Ankle Surgery",
"state": "IL",
"license": "016-005031",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "016005031",
"state": "IL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RAILROAD MEDICARE",
"identifier": "P00347050",
"state": "IL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUECROSS",
"identifier": "04932511",
"state": "IL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Libertyville, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 25, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.