Provider Demographics
NPI:1245415850
Name:BROOKFIELD PODIATRY CENTER
Entity Type:Organization
Organization Name:BROOKFIELD PODIATRY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-390-8360
Mailing Address - Street 1:21041 W SNOWBERRY LN
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-6413
Mailing Address - Country:US
Mailing Address - Phone:630-390-8360
Mailing Address - Fax:708-424-1084
Practice Address - Street 1:14 S. ADDISON STREET
Practice Address - Street 2:
Practice Address - City:BENSENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60106
Practice Address - Country:US
Practice Address - Phone:630-390-8360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THOMAS J. MACK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-02
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003689213E00000X
261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatricGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT38159Medicare UPIN
IL0850490001Medicare NSC
IL723340Medicare PIN