Provider Demographics
NPI:1023020997
Name:WAXBERG ORTHOPEDIC SHOES INC
Entity Type:Organization
Organization Name:WAXBERG ORTHOPEDIC SHOES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:WAXBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-965-3338
Mailing Address - Street 1:7013 W DEMPSTER ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-2130
Mailing Address - Country:US
Mailing Address - Phone:847-965-3338
Mailing Address - Fax:847-965-3337
Practice Address - Street 1:7013 W DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-2130
Practice Address - Country:US
Practice Address - Phone:847-965-3338
Practice Address - Fax:847-965-3337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000297127OtherBCBS ANTHEM OF OHIO
IL0001670958OtherBCBS OF IL
IL=========OtherTAX ID NUMBER
IL0001670958OtherBCBS OF IL
IL0369520001Medicare NSC