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NPI Code Detail

MEDICARE: EVANSTON PODIATRY CENTER

MEDICARE: EVANSTON PODIATRY CENTER
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1213E00000XPodiatristIL
2213ES0131XFoot Surgery PodiatristIL
3213EP1101XPrimary Podiatric Medicine PodiatristIL
4213EP0504XPublic Medicine PodiatristIL
5213ES0103XFoot & Ankle Surgery PodiatristIL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1600-15184OTHERILBCBS

General Provider Information

NPI Number : 1043202559
Entity Type Code : Organization
Provider Name (Legal Business Name) : EVANSTON PODIATRY CENTER
Provider Business Mailing Address
First Line : 9933 S WESTERN AVE
Second Line : SUITE 102
City : CHICAGO
State : IL
Zip : 60643-1810
Country : US
Telephone Number : 847-424-9888
Fax Number : 847-424-9649
Provider Business Practice Location Address
First Line : 1605 CHICAGO AVE
Second Line :
City : EVANSTON
State : IL
Zip : 60201-4504
Country : US
Telephone Number : 847-424-9888
Fax Number : 847-424-9649
Authorized Official
Title or Position : MEDICAL DIRECTOR & CEO
Name : MRS. FORTUNEE MASSUDA
Credential : DPM
Telephone Number : 847-424-9888
Provider Enumeration Date : 08/19/2005
Last Update Date : 07/03/2008

Similar Medicare Providers

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Practice Location Address:
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1093948960 — MISS LACEY MARIE WINTER DPT
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1942740881 — KHALIAH YVONNE ELLISTON
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Practice Fax:

Directions to “EVANSTON PODIATRY CENTER ” Practice Location

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