Provider Demographics
NPI:1174666192
Name:ALEX J BUIVIDAS & THOMAS A BUIVIDAS PTR
Entity Type:Organization
Organization Name:ALEX J BUIVIDAS & THOMAS A BUIVIDAS PTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BUIVIDAS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:773-847-6784
Mailing Address - Street 1:4554 S ARCHER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-2954
Mailing Address - Country:US
Mailing Address - Phone:773-847-6784
Mailing Address - Fax:773-847-6883
Practice Address - Street 1:4554 S ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-2954
Practice Address - Country:US
Practice Address - Phone:773-847-6784
Practice Address - Fax:773-847-6883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016002967213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016002967Medicaid
IL0393590001Medicare NSC
ILT37627Medicare UPIN
IL016002967Medicaid