Provider Demographics
NPI: | 1376525592 |
---|---|
Name: | MAHONEY, LYNETTE (DPM) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | LYNETTE |
Middle Name: | |
Last Name: | MAHONEY |
Suffix: | |
Gender: | F |
Credentials: | DPM |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 404 MCHENRY RD |
Mailing Address - Street 2: | |
Mailing Address - City: | BUFFALO GROVE |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60089-6740 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 847-285-4200 |
Mailing Address - Fax: | 847-885-0130 |
Practice Address - Street 1: | 404 MCHENRY RD |
Practice Address - Street 2: | |
Practice Address - City: | BUFFALO GROVE |
Practice Address - State: | IL |
Practice Address - Zip Code: | 60089-6740 |
Practice Address - Country: | US |
Practice Address - Phone: | 847-285-4200 |
Practice Address - Fax: | 847-885-0130 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-11-15 |
Last Update Date: | 2020-07-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 016004956 | 213E00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 213E00000X | Podiatric Medicine & Surgery Service Providers | Podiatrist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IL | 016-004956 | Medicaid | |
IL | P00442755 | Other | MEDICARE RAILROAD |
IL | P00442755 | Other | MEDICARE RAILROAD |
IL | 016-004956 | Medicaid | |
IL | K38251 | Medicare PIN | |
IL | P00442755 | Other | MEDICARE RAILROAD |