Provider Demographics
NPI:1407934888
Name:DEZANEK PODIATRY CENTER LTD
Entity Type:Organization
Organization Name:DEZANEK PODIATRY CENTER LTD
Other - Org Name:ROBERT C DEZANEK DPM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORP PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:DEZANEK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:773-283-1911
Mailing Address - Street 1:5916 W HIGGINS AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-1905
Mailing Address - Country:US
Mailing Address - Phone:773-283-1911
Mailing Address - Fax:
Practice Address - Street 1:5916 W HIGGINS AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-1905
Practice Address - Country:US
Practice Address - Phone:773-283-1911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003970213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0060001570OtherBLUE CROSS
IL3394649896063002Medicaid
IL480009595OtherRAILROAD MEDICARE
IL3394649896063002Medicaid
IL216578Medicare PIN