MEDICARE: LOGAN SQUARE FOOT CENTER PC

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
1	332B00000X	Durable Medical Equipment & Medical Supplies	016002700	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0060020807	OTHER	IL	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1952358574	OTHER	IL	NPI

General Provider Information

NPI Number	:	1417126301
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOGAN SQUARE FOOT CENTER PC

Provider Business Mailing Address
First Line	:	2831 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-7403
Country	:	US
Telephone Number	:	773-772-4440
Fax Number	:	773-772-4461

Provider Business Practice Location Address
First Line	:	2831 N MILWAUKEE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-7403
Country	:	US
Telephone Number	:	773-772-4440
Fax Number	:	773-772-4461

Authorized Official
Title or Position	:	DOCTOR
Name	:	DR. GARRY S. ISENSTADT
Credential	:	D.P.M.
Telephone Number	:	773-772-4440

Provider Enumeration Date	:	02/25/2008
Last Update Date	:	09/06/2013

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