MEDICARE: DEZANEK PODIATRY CENTER 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	213E00000X	Podiatrist	016003970	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	480009595	OTHER	IL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0060001570	OTHER	IL	BLUE CROSS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407934888
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEZANEK PODIATRY CENTER LTD

Provider Business Mailing Address
First Line	:	5916 W HIGGINS AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-1905
Country	:	US
Telephone Number	:	773-283-1911
Fax Number	:

Provider Business Practice Location Address
First Line	:	5916 W HIGGINS AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60630-1905
Country	:	US
Telephone Number	:	773-283-1911
Fax Number	:

Authorized Official
Title or Position	:	CORP PRESIDENT
Name	:	DR. ROBERT CHARLES DEZANEK
Credential	:	DPM
Telephone Number	:	773-283-1911

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	12/26/2014

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Directions to “DEZANEK PODIATRY CENTER LTD ” Practice Location

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