Provider Demographics
NPI:1417126301
Name:LOGAN SQUARE FOOT CENTER PC
Entity Type:Organization
Organization Name:LOGAN SQUARE FOOT CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GARRY
Authorized Official - Middle Name:S
Authorized Official - Last Name:ISENSTADT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:773-772-4440
Mailing Address - Street 1:2831 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-7403
Mailing Address - Country:US
Mailing Address - Phone:773-772-4440
Mailing Address - Fax:773-772-4461
Practice Address - Street 1:2831 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-7403
Practice Address - Country:US
Practice Address - Phone:773-772-4440
Practice Address - Fax:773-772-4461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016002700332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0060020807OtherBCBS
IL016002700Medicaid
IL1952358574OtherNPI
IL016002700Medicaid
IL5765940001Medicare NSC
IL213713Medicare PIN