Healthcare Provider Details

I. General information

NPI: 1396968053
Provider Name (Legal Business Name): PODIATRIC MANAGEMENT SYSTEMS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 09/02/2020
Certification Date: 09/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 ELA RD
LAKE ZURICH IL
60047-2385
US

IV. Provider business mailing address

70 E LAKE ST STE 1102
CHICAGO IL
60601-7499
US

V. Phone/Fax

Practice location:
  • Phone: 847-540-9949
  • Fax: 847-540-9971
Mailing address:
  • Phone: 312-372-1160
  • Fax: 312-372-3346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number StateIL

VIII. Authorized Official

Name: MS. PATRICE COOPER
Title or Position: ADMINISTRATOR
Credential:
Phone: 312-372-1160