=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003525783
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAURA M SHEA DPM PODIATRY SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2022
-----------------------------------------------------
Last Update Date | 11/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6323 N AVONDALE AVE STE 103
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60631-1962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-993-7423
-----------------------------------------------------
Fax | 847-993-7420
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6323 N AVONDALE AVE STE 103
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60631-1962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-993-7423
-----------------------------------------------------
Fax | 847-993-7420
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICIAN
-----------------------------------------------------
Name | DR. LAURA M SHEA
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 708-289-7300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP1100X
-----------------------------------------------------
Taxonomy Name | Podiatric Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------