1396968053 NPI number — PODIATRIC MANAGEMENT SYSTEMS LLC

Table of content: (NPI 1396968053)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396968053 NPI number — PODIATRIC MANAGEMENT SYSTEMS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PODIATRIC MANAGEMENT SYSTEMS LLC
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:
1396968053
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
70 E LAKE ST STE 1102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60601-7499
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-372-1160
Provider Business Mailing Address Fax Number:
312-372-3346

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
765 ELA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE ZURICH
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60047-2385
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-540-9949
Provider Business Practice Location Address Fax Number:
847-540-9971
Provider Enumeration Date:
04/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COOPER
Authorized Official First Name:
PATRICE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
312-372-1160

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213EP1101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 90001026 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 1621423 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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