Provider Demographics
NPI:1134279326
Name:THE PEDORTHIC SHOPPE INC
Entity Type:Organization
Organization Name:THE PEDORTHIC SHOPPE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELANGELO
Authorized Official - Middle Name:
Authorized Official - Last Name:SCAFIDI
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED PEDOTHIST
Authorized Official - Phone:708-453-4900
Mailing Address - Street 1:PO BOX 705
Mailing Address - Street 2:
Mailing Address - City:ITASCA
Mailing Address - State:IL
Mailing Address - Zip Code:60143-0705
Mailing Address - Country:US
Mailing Address - Phone:708-453-4900
Mailing Address - Fax:708-453-3338
Practice Address - Street 1:8344 W LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:NORRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60706-3152
Practice Address - Country:US
Practice Address - Phone:708-453-4900
Practice Address - Fax:708-453-3338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332BC3200X332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1272630001Medicare NSC