Brian    King    DPM
Contract Details
Facility name
Provider ID
P000005707
NPI
1962439091
Tax ID
363651907
Effective Date
4/1/2012
Last Updated
8/5/2013
Direct Contract
Yes
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
96.00
Location Details
Address
6142 West Roosevelt Rd
Oak Park, IL 60304
United States
County
Cook
Phone
7088480021 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Podiatry
Map
Address