1780854661 NPI number — GOLD COAST PODIATRY CENTER, LLC

Table of content: (NPI 1780854661)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780854661 NPI number — GOLD COAST PODIATRY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOLD COAST PODIATRY CENTER, 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:
1780854661
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9933 S WESTERN AVE
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60643-1810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-233-3800
Provider Business Mailing Address Fax Number:
773-233-2513

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3000 N HALSTED ST
Provider Second Line Business Practice Location Address:
SUITE 621
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60657-5188
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-871-2250
Provider Business Practice Location Address Fax Number:
773-697-0134
Provider Enumeration Date:
03/06/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MASSUDA
Authorized Official First Name:
FORTUNEE
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR/CEO
Authorized Official Telephone Number:
773-752-2111

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213ES0131X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 01623607 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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