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NPI Code Detail

MEDICARE: GOLD COAST PODIATRY CENTER, LLC

MEDICARE: GOLD COAST PODIATRY CENTER, LLC
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
1016-23607OTHERILBCBS

General Provider Information

NPI Number : 1144212663
Entity Type Code : Organization
Provider Name (Legal Business Name) : GOLD COAST PODIATRY CENTER, LLC
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 : 773-233-3800
Fax Number : 773-233-2513
Provider Business Practice Location Address
First Line : 750 N FRANKLIN ST
Second Line : SUITE 102
City : CHICAGO
State : IL
Zip : 60654-6263
Country : US
Telephone Number : 312-280-7886
Fax Number : 312-280-9547
Authorized Official
Title or Position : MEDICAL DIRECTOR & CEO
Name : MRS. FORTUNEE MASSUDA
Credential : DPM
Telephone Number : 312-280-7886
Provider Enumeration Date : 08/19/2005
Last Update Date : 04/22/2013

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Directions to “GOLD COAST PODIATRY CENTER, LLC ” Practice Location

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