1447242862 NPI number — HYDE PARK PODIATRY CTR LTD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447242862 NPI number — HYDE PARK PODIATRY CTR LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HYDE PARK PODIATRY CTR LTD
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:
1447242862
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2011
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:
SUITE102
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:
1644 E 53RD ST
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:
60615-4210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-752-2111
Provider Business Practice Location Address Fax Number:
773-233-6703
Provider Enumeration Date:
08/22/2005

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: 213E00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0131X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213EP1101X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213EP0504X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , 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)

  • Identifier: 600-15187 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".