Healthcare Provider Details

I. General information

NPI: 1265942080
Provider Name (Legal Business Name): PERFORMANCE PODIATRY PARTNERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2017
Last Update Date: 10/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4805 N CLAREMONT AVE COMMERCIAL UNIT 1
CHICAGO IL
60625
US

IV. Provider business mailing address

2120 N WINCHESTER AVE
CHICAGO IL
60614-3915
US

V. Phone/Fax

Practice location:
  • Phone: 312-579-3150
  • Fax:
Mailing address:
  • Phone: 508-259-8466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. SUPNA REILLY
Title or Position: PHYSICIAN
Credential: DPM
Phone: 508-259-8466