Provider Demographics
NPI:1871940882
Name:PREFERRED PODIATRY GROUP PC
Entity type:Organization
Organization Name:PREFERRED PODIATRY GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL COUNSEL
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MICHAEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-504-5002
Mailing Address - Street 1:PO BOX 917
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60065-0917
Mailing Address - Country:US
Mailing Address - Phone:847-504-5000
Mailing Address - Fax:844-443-0082
Practice Address - Street 1:40 SKOKIE BLVD STE 520
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1601
Practice Address - Country:US
Practice Address - Phone:847-504-5007
Practice Address - Fax:844-443-0082
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREFERRED PODIATRY GROUP PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-05-19
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060005901213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO504482407Medicaid