=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689652570
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY PODIATRY CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2006
-----------------------------------------------------
Last Update Date | 01/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 720 BROM CT STE 201
-----------------------------------------------------
City | NAPERVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60540-6534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-355-3668
-----------------------------------------------------
Fax | 630-355-3016
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 720 BROM CT STE 201
-----------------------------------------------------
City | NAPERVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60540-6534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-355-3668
-----------------------------------------------------
Fax | 630-355-3016
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LAWRENCE M KOSOVA
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 630-355-3668
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP1100X
-----------------------------------------------------
Taxonomy Name | Podiatric Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------