Healthcare Provider Details

I. General information

NPI: 1447681127
Provider Name (Legal Business Name): NORTHSIDE FOOT & ANKLE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2013
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 N FRANKLIN ST STE 102
CHICAGO IL
60654-6263
US

IV. Provider business mailing address

750 N FRANKLIN ST STE 102
CHICAGO IL
60654-6263
US

V. Phone/Fax

Practice location:
  • Phone: 312-280-7886
  • Fax: 312-280-9547
Mailing address:
  • Phone: 312-280-7886
  • Fax: 312-280-9547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY STEPHEN KRUSE
Title or Position: OWNER/CEO
Credential: DPM
Phone: 312-280-7886