Healthcare Provider Details

I. General information

NPI: 1801142740
Provider Name (Legal Business Name): BEB PODIATRY SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2012
Last Update Date: 09/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 DEER POINT DR
HAWTHORN WOODS IL
60047-8010
US

IV. Provider business mailing address

36 DEER POINT DR
HAWTHORN WOODS IL
60047-8010
US

V. Phone/Fax

Practice location:
  • Phone: 847-922-4315
  • Fax: 847-725-2155
Mailing address:
  • Phone: 847-922-4315
  • Fax: 847-725-2155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016.003631
License Number StateIL

VIII. Authorized Official

Name: BRIAN BACARDI
Title or Position: PRESIDENT
Credential:
Phone: 847-922-4315