1063647253 NPI number — FOOT & ANKLE HEALTH CARE CENTER LTD

Table of content: (NPI 1063647253)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063647253 NPI number — FOOT & ANKLE HEALTH CARE CENTER LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOT & ANKLE HEALTH CARE CENTER 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:
EUROPEAN FOOT & ANKLE CLINIC
Provider Other Organization Name Type Code:
3
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:
1063647253
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5501 W BELMONT AVE
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:
60641-4130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4000 S WESTERN AVE
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:
60609-2265
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-376-3100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PODOLSKIY
Authorized Official First Name:
GALINA
Authorized Official Middle Name:
Authorized Official Title or Position:
D.P.M.
Authorized Official Telephone Number:
773-205-0106

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  016004982 , 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)





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