Provider Demographics
NPI:1144600305
Name:NORTHWEST PODIATRY CENTER
Entity Type:Organization
Organization Name:NORTHWEST PODIATRY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRYNICZKA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:847-608-9494
Mailing Address - Street 1:234 RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60177-2274
Mailing Address - Country:US
Mailing Address - Phone:847-608-9494
Mailing Address - Fax:847-608-9499
Practice Address - Street 1:234 RANDALL RD
Practice Address - Street 2:
Practice Address - City:SOUTH ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60177-2274
Practice Address - Country:US
Practice Address - Phone:847-608-9494
Practice Address - Fax:847-608-9499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-03
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-002778332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL367690Medicare UPIN