=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861640708
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOOTWISE PODIATRY, LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2008
-----------------------------------------------------
Last Update Date | 09/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4646 N MARINE DR SUITE # A6700
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640-5759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-837-1076
-----------------------------------------------------
Fax | 847-837-9228
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 460
-----------------------------------------------------
City | LIBERTYVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60048-0460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-837-1076
-----------------------------------------------------
Fax | 847-837-9228
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARY M. MARTINO
-----------------------------------------------------
Credential | D.P.M.
-----------------------------------------------------
Telephone | 847-837-1076
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 016-004178
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------