1720037138 NPI number — PREFERRED PODIATRY GROUP PC

Table of content: (NPI 1720037138)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720037138 NPI number — PREFERRED PODIATRY GROUP PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREFERRED PODIATRY GROUP PC
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:
1720037138
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 772294
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48277-0917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-504-5000
Provider Business Mailing Address Fax Number:
844-443-0082

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
168 N CLINTON ST FL 3
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:
60661-1425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-504-5000
Provider Business Practice Location Address Fax Number:
847-504-5015
Provider Enumeration Date:
05/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WAI
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
C
Authorized Official Title or Position:
CFO/AO
Authorized Official Telephone Number:
773-627-2924

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 060005901 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1720037138 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200623610A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: C12116 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 281333901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 43265500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: CB3726 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 122195500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 73780081 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: CH4840 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: DW2909 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 7100257260 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: DW2427 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".
  • Identifier: DX1124 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: DR6817 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 504482407 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: DS6430 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: DU2423 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: Q030004 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100253080E , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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