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General NPI Number Information
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NPI Number | 1639455470
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Entity Type | Organization
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Legal Business Name | PRAIRIE PATH PODIATRY, P.C.
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Dates
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Enumeration Date | 10/25/2011
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Last Update Date | 01/14/2015
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Provider Practice Location Address
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Address Line | 4 S 6TH ST
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City | GENEVA
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State | IL
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Zip | 60134-2163
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Country | US
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Telephone | 630-845-3338
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Fax | 630-845-0557
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Provider Business Mailing Address
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Address Line | 4 S 6TH ST
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City | GENEVA
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State | IL
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Zip | 60134-2163
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Country | US
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Telephone | 630-845-3338
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Fax | 630-845-0557
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Authorized Official
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Title or Position | PRESIDENT
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Name | PETER C. TSANG
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Credential | DPM
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Telephone | 630-845-3338
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP1100X
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Taxonomy Name | Podiatric Clinic/Center
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License Number | 016004771
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License Number State | IL
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