Healthcare Provider Details

I. General information

NPI: 1437479839
Provider Name (Legal Business Name): JOHN RICHARD SIMONOVICH DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2010
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 E ERIE ST SUITE 2230
CHICAGO IL
60611-2987
US

IV. Provider business mailing address

259 E ERIE ST STE 2230
CHICAGO IL
60611-3370
US

V. Phone/Fax

Practice location:
  • Phone: 312-926-6000
  • Fax: 312-926-8267
Mailing address:
  • Phone: 312-695-6800
  • Fax: 312-926-8267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016005484
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016005484
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: