Provider Demographics
NPI:1346407301
Name:BERWYN FOOT & ANKLE CENTER
Entity Type:Organization
Organization Name:BERWYN FOOT & ANKLE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:POTACH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:708-484-3338
Mailing Address - Street 1:3100 SOUTH OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3031
Mailing Address - Country:US
Mailing Address - Phone:708-484-3338
Mailing Address - Fax:708-484-2059
Practice Address - Street 1:3100 SOUTH OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3031
Practice Address - Country:US
Practice Address - Phone:708-484-3338
Practice Address - Fax:708-484-2059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2009-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004088261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL774900Medicare UPIN