Healthcare Provider Details

I. General information

NPI: 1245415850
Provider Name (Legal Business Name): BROOKFIELD PODIATRY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2008
Last Update Date: 05/07/2020
Certification Date: 05/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 S. ADDISON STREET
BENSENVILLE IL
60106
US

IV. Provider business mailing address

21041 W SNOWBERRY LN
PLAINFIELD IL
60544-6413
US

V. Phone/Fax

Practice location:
  • Phone: 630-390-8360
  • Fax:
Mailing address:
  • Phone: 630-390-8360
  • Fax: 708-424-1084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016003689
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS J. MACK
Title or Position: OWNER
Credential:
Phone: 630-390-8360