Basic Information
| Provider Information | |||||||||
| NPI: | 1396968053 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PODIATRIC MANAGEMENT SYSTEMS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 70 E LAKE ST STE 1102 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606017499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3123721160 | ||||||||
| FaxNumber: | 3123723346 | ||||||||
| Practice Location | |||||||||
| Address1: | 765 ELA RD | ||||||||
| Address2: | |||||||||
| City: | LAKE ZURICH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600472385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475409949 | ||||||||
| FaxNumber: | 8475409971 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 09/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | COOPER | ||||||||
| AuthorizedOfficialFirstName: | PATRICE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3123721160 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 09/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | IL | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213EP1101X | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 90001026 | 01 | IN | BCBS PROVIDER NUMBER | OTHER | 1621423 | 01 | IL | BCBS PROVIDER NUMBER | OTHER |