Provider Demographics
NPI:1003525783
Name:LAURA M SHEA DPM PODIATRY SERVICES
Entity Type:Organization
Organization Name:LAURA M SHEA DPM PODIATRY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHEA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:708-289-7300
Mailing Address - Street 1:6323 N AVONDALE AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-1962
Mailing Address - Country:US
Mailing Address - Phone:847-993-7423
Mailing Address - Fax:847-993-7420
Practice Address - Street 1:6323 N AVONDALE AVE STE 103
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-1962
Practice Address - Country:US
Practice Address - Phone:847-993-7423
Practice Address - Fax:847-993-7420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005081Medicaid