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General NPI Number Information
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NPI Number | 1760686075
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Entity Type | Organization
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Legal Business Name | FOOTWISE PODIATRY, LTD.
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Dates
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Enumeration Date | 06/12/2007
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Last Update Date | 01/01/2012
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Provider Practice Location Address
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Address Line | 1324 KETTERING RD
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City | MUNDELEIN
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State | IL
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Zip | 60060-5364
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Country | US
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Telephone | 847-837-1076
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Fax | 847-837-9228
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Provider Business Mailing Address
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Address Line | 1324 KETTERING RD
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City | MUNDELEIN
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State | IL
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Zip | 60060-5364
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Country | US
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Telephone | 847-837-1076
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Fax | 847-837-9228
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARY M. MARTINO
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Credential | D.P.M.
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Telephone | 847-837-1076
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 016-004178
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License Number State | IL
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