1730352907 NPI number — PODIATRY IN MOTION, INC.

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 1730352907 NPI number — PODIATRY IN MOTION, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PODIATRY IN MOTION, INC.
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:
1730352907
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/11/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1046 N WOOD ST
Provider Second Line Business Mailing Address:
#1-R
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60622-7273
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-862-4732
Provider Business Mailing Address Fax Number:
773-862-4732

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1046 N WOOD ST
Provider Second Line Business Practice Location Address:
#1-R
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60622-7273
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-862-4732
Provider Business Practice Location Address Fax Number:
773-862-4732
Provider Enumeration Date:
04/09/2008

Additional Information

Authorized Official

Authorized Official Last Name:
HEIRING
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
RENEE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
773-862-4732

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  016-004846 , 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: 0001632315 . This is a "BLUE CROSS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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