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	License Number State
1	213E00000X	Podiatrist	IN
2	213EP1101X	Primary Podiatric Medicine Podiatrist	IN
3	213ES0131X	Foot Surgery Podiatrist	IN
4	213EP0504X	Public Medicine Podiatrist	IN
5	213ES0103X	Foot & Ankle Surgery Podiatrist	IN

Other Identifiers

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

General Provider Information

NPI Number	:	1801888359
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	:	4320 FIR ST
Second Line	:
City	:	EAST CHICAGO
State	:	IN
Zip	:	46312-3052
Country	:	US
Telephone Number	:	219-398-0100
Fax Number	:	219-398-4192

Authorized Official
Title or Position	:	MEDICAL DIRECTOR/CEO
Name	:	MRS. FORTUNEE MASSUDA
Credential	:	DPM
Telephone Number	:	219-398-0100

Provider Enumeration Date	:	08/19/2005
Last Update Date	:	02/20/2014

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

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