Healthcare Provider Details

I. General information

NPI: 1124286927
Provider Name (Legal Business Name): FOOTCO ORTHOPEDIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2008
Last Update Date: 05/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3723 N SOUTHPORT AVE
CHICAGO IL
60613-3718
US

IV. Provider business mailing address

PO BOX 13377
CHICAGO IL
60613-0377
US

V. Phone/Fax

Practice location:
  • Phone: 312-409-2175
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number212.000115
License Number StateIL

VIII. Authorized Official

Name: TIM PORCELLI
Title or Position: DIRECTOR, CHIEF CLINICIAN
Credential: LC PED
Phone: 312-409-2175