1528250669 NPI number — PREMIER PODIATRY SERVICES, LTD

Table of content: (NPI 1528250669)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528250669 NPI number — PREMIER PODIATRY SERVICES, LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER PODIATRY SERVICES, 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:
1528250669
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7126 N LINCOLN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINCOLNWOOD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60712-2234
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-866-9800
Provider Business Mailing Address Fax Number:
773-866-1733

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7126 N LINCOLN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINCOLNWOOD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60712-2234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-866-9800
Provider Business Practice Location Address Fax Number:
773-866-1733
Provider Enumeration Date:
08/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PAHOLAK
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
DANIEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
773-866-9800

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1208030001 . This is a "ADMINISTAR" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 016004340 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0001623503 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: CG8029 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 5410292 . This is a "CIGNA" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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