Provider Demographics
NPI:1902092554
Name:CANEVA FOOT & ANKLE CLINIC, LTD.
Entity Type:Organization
Organization Name:CANEVA FOOT & ANKLE CLINIC, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:CANEVA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:815-741-0791
Mailing Address - Street 1:200 N HAMMES AVE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-6677
Mailing Address - Country:US
Mailing Address - Phone:815-741-0791
Mailing Address - Fax:815-741-9576
Practice Address - Street 1:200 N HAMMES AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6677
Practice Address - Country:US
Practice Address - Phone:815-741-0791
Practice Address - Fax:815-741-9576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004255213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0528550002Medicare NSC
ILP15847Medicare PIN
ILDC1289Medicare PIN
IL648030Medicare PIN
IL648031Medicare PIN
ILP15844Medicare PIN
ILCF4187Medicare PIN