Healthcare Provider Details

I. General information

NPI: 1316117211
Provider Name (Legal Business Name): BEVERLY PODIATRY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2008
Last Update Date: 12/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9501 W 144TH PL 106
ORLAND PARK IL
60462-2561
US

IV. Provider business mailing address

9933 S WESTERN AVE SUITE 102
CHICAGO IL
60643-1810
US

V. Phone/Fax

Practice location:
  • Phone: 708-403-3668
  • Fax: 708-403-3684
Mailing address:
  • Phone: 773-233-3800
  • Fax: 773-233-2513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number StateIL

VIII. Authorized Official

Name: MRS. FORTUNEE MASSUDA
Title or Position: MEDICAL DIRECTOR/CEO
Credential: DPM
Phone: 773-752-2111