Healthcare Provider Details

I. General information

NPI: 1700123734
Provider Name (Legal Business Name): CHICAGO FOOT & ORTHOPEDIC CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2013
Last Update Date: 01/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3918 W 63RD ST
CHICAGO IL
60629-4604
US

IV. Provider business mailing address

2801 W CERMAK RD
CHICAGO IL
60623-3513
US

V. Phone/Fax

Practice location:
  • Phone: 773-376-7200
  • Fax: 773-376-9211
Mailing address:
  • Phone: 773-376-7200
  • Fax: 773-376-9211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number016004154
License Number StateIL

VIII. Authorized Official

Name: AMIN MASHOUF
Title or Position: ADMINISTRATOR
Credential:
Phone: 773-376-7200