MEDICARE: NORTHWEST INDIANA PODIATRY CLINIC, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	213E00000X	Podiatrist
2	213EP0504X	Public Medicine Podiatrist
3	213ES0131X	Foot Surgery Podiatrist
4	213ER0200X	Radiology Podiatrist
5	213ES0000X	Sports Medicine Podiatrist
6	213EP1101X	Primary Podiatric Medicine Podiatrist
7	211D00000X	Podiatric Assistant
8	213ES0103X	Foot & Ankle Surgery Podiatrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	90001145	OTHER	IN	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639375058
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHWEST INDIANA PODIATRY CLINIC, LLC

Provider Business Mailing Address
First Line	:	9933 S WESTERN AVE
Second Line	:	SUITE 102
City	:	CHICAGO
State	:	IL
Zip	:	60643-1810
Country	:	US
Telephone Number	:	773-233-3800
Fax Number	:	773-233-2513

Provider Business Practice Location Address
First Line	:	1534 119TH ST
Second Line	:
City	:	WHITING
State	:	IN
Zip	:	46394-1733
Country	:	US
Telephone Number	:	219-659-0630
Fax Number	:	219-473-0018

Authorized Official
Title or Position	:	MEDICAL DIRECTOR & CEO
Name	:	DR. FORTUNEE MASSUDA
Credential	:	DPM
Telephone Number	:	773-233-3800

Provider Enumeration Date	:	06/22/2007
Last Update Date	:	11/12/2009

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Directions to “NORTHWEST INDIANA PODIATRY CLINIC, LLC ” Practice Location

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