Healthcare Provider Details

I. General information

NPI: 1962574103
Provider Name (Legal Business Name): SOUTH CHICAGO FOOT & ANKLE CENTER, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 09/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1706 E 87TH ST
CHICAGO IL
60617-2740
US

IV. Provider business mailing address

1706 E 87TH ST
CHICAGO IL
60617-2740
US

V. Phone/Fax

Practice location:
  • Phone: 773-374-5300
  • Fax: 773-374-5860
Mailing address:
  • Phone: 773-374-5300
  • Fax: 773-374-5860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JONDELLE JENKINS
Title or Position: PRESIDENT
Credential: DPM
Phone: 773-374-5300