MEDICARE: THE PEDORTHIC SHOPPE INC

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	332BC3200X	Customized Equipment (DME)	332BC3200X	IL

General Provider Information

NPI Number	:	1134279326
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE PEDORTHIC SHOPPE INC

Provider Business Mailing Address
First Line	:	PO BOX 705
Second Line	:
City	:	ITASCA
State	:	IL
Zip	:	60143-0705
Country	:	US
Telephone Number	:	708-453-4900
Fax Number	:	708-453-3338

Provider Business Practice Location Address
First Line	:	8344 W LAWRENCE AVE
Second Line	:
City	:	NORRIDGE
State	:	IL
Zip	:	60706-3152
Country	:	US
Telephone Number	:	708-453-4900
Fax Number	:	708-453-3338

Authorized Official
Title or Position	:	OWNER PRESIDENT
Name	:	MICHELANGELO SCAFIDI
Credential	:	CERTIFIED PEDOTHIST
Telephone Number	:	708-453-4900

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	08/22/2020

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