MEDICARE: CHICAGO PODIATRY SURGICORE, LTD.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1114968542
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICAGO PODIATRY SURGICORE, LTD.

Provider Business Mailing Address
First Line	:	1518 E 87TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-6525
Country	:	US
Telephone Number	:	773-978-1244
Fax Number	:	773-978-4606

Provider Business Practice Location Address
First Line	:	1518 E 87TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60619-6525
Country	:	US
Telephone Number	:	773-978-1244
Fax Number	:	773-978-4606

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JEREMY COWAN
Credential	:	D.P.M.
Telephone Number	:	773-978-1244

Provider Enumeration Date	:	06/09/2006
Last Update Date	:	10/29/2007

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