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General NPI Number Information
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NPI Number | 1427219500
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Entity Type | Organization
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Legal Business Name | A GOLD COAST FOOT CLINIC, LTD.
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Dates
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Enumeration Date | 06/20/2008
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Last Update Date | 11/24/2008
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Provider Practice Location Address
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Address Line | 845 N MICHIGAN AVE 915W
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City | CHICAGO
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State | IL
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Zip | 60611-2252
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Country | US
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Telephone | 312-266-7404
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Fax | 312-494-9110
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Provider Business Mailing Address
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Address Line | 845 N MICHIGAN AVE 915W
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City | CHICAGO
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State | IL
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Zip | 60611-2252
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Country | US
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Telephone | 312-266-7404
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Fax | 312-494-9110
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RICHARD C BENNETT II
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Credential | D.P.M.
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Telephone | 312-266-7404
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 016-004014
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License Number State | IL
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