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General NPI Number Information
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NPI Number | 1881026185
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Entity Type | Organization
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Legal Business Name | MICHIGAN AVE PODIATRY LLC 1
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Dates
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Enumeration Date | 08/08/2013
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Last Update Date | 08/26/2015
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Provider Practice Location Address
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Address Line | 30 N MICHIGAN AVE SUITE 720
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City | CHICAGO
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State | IL
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Zip | 60602-3809
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Country | US
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Telephone | 312-701-0770
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Fax | 312-701-0705
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Provider Business Mailing Address
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Address Line | 30 N MICHIGAN AVE SUITE 720
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City | CHICAGO
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State | IL
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Zip | 60602-3809
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Country | US
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Telephone | 312-701-0770
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Fax | 312-701-0705
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Authorized Official
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Title or Position | STOCKHOLDER
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Name | DR. PAM A EERNISSE
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Credential | DPM
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Telephone | 312-701-0770
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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 | 016004918
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License Number State | IL
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