Healthcare Provider Details

I. General information

NPI: 1982957528
Provider Name (Legal Business Name): ASG ONSITE PODIATRY OF WI 1 SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2012
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 S RIVERSIDE PLZ STE 19 EAST
CHICAGO IL
60606-3728
US

IV. Provider business mailing address

10 S RIVERSIDE PLZ STE 19 EAST
CHICAGO IL
60606-3728
US

V. Phone/Fax

Practice location:
  • Phone: 773-770-0140
  • Fax: 312-277-6757
Mailing address:
  • Phone: 773-770-0140
  • Fax: 312-277-6757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: YEV GRAY
Title or Position: OWNER
Credential: DPM
Phone: 773-770-0140