Healthcare Provider Details

I. General information

NPI: 1235917238
Provider Name (Legal Business Name): CHICAGO PODIATRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2023
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 W 95TH ST STE 203
OAK LAWN IL
60453-2574
US

IV. Provider business mailing address

11155 KAREN DR
ORLAND PARK IL
60467-4481
US

V. Phone/Fax

Practice location:
  • Phone: 708-274-7876
  • Fax:
Mailing address:
  • Phone: 260-580-3677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: JANNAH BACCHUS
Title or Position: CO-OWNER
Credential:
Phone: 260-580-3677