MEDICARE: MICHIGAN AVE PODIATRY LLC 1

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	213ES0103X	Foot & Ankle Surgery Podiatrist	016004918	IL

General Provider Information

NPI Number	:	1881026185
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHIGAN AVE PODIATRY LLC 1

Provider Business Mailing Address
First Line	:	30 N MICHIGAN AVE
Second Line	:	SUITE 720
City	:	CHICAGO
State	:	IL
Zip	:	60602-3809
Country	:	US
Telephone Number	:	312-701-0770
Fax Number	:	312-701-0705

Provider Business Practice Location Address
First Line	:	30 N MICHIGAN AVE
Second Line	:	SUITE 720
City	:	CHICAGO
State	:	IL
Zip	:	60602-3809
Country	:	US
Telephone Number	:	312-701-0770
Fax Number	:	312-701-0705

Authorized Official
Title or Position	:	STOCKHOLDER
Name	:	DR. PAM A EERNISSE
Credential	:	DPM
Telephone Number	:	312-701-0770

Provider Enumeration Date	:	08/08/2013
Last Update Date	:	08/26/2015

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