1174060917 NPI number — PREFERRED PODIATRY GROUP PC

Table of content: (NPI 1174060917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174060917 NPI number — PREFERRED PODIATRY GROUP PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREFERRED PODIATRY GROUP PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174060917
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
425 HUEHL RD
Provider Second Line Business Mailing Address:
UNIT #13
Provider Business Mailing Address City Name:
NORTHBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60062-2319
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-504-5000
Provider Business Mailing Address Fax Number:
844-443-0082

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
168 N CLINTON ST FL 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60661-1425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-504-5007
Provider Business Practice Location Address Fax Number:
844-443-0082
Provider Enumeration Date:
01/31/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MICHAEL
Authorized Official First Name:
MELANIE
Authorized Official Middle Name:
S
Authorized Official Title or Position:
CHIEF OPERATIONS OFFICER
Authorized Official Telephone Number:
847-504-5002

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  060005901 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)