Provider Demographics
NPI:1417337825
Name:NORTHWEST PODIATRY CENTER
Entity Type:Organization
Organization Name:NORTHWEST PODIATRY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRYNICZKA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:630-830-2155
Mailing Address - Street 1:2124 OGDEN AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-7514
Mailing Address - Country:US
Mailing Address - Phone:630-585-8087
Mailing Address - Fax:630-585-8024
Practice Address - Street 1:2124 OGDEN AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-7514
Practice Address - Country:US
Practice Address - Phone:630-585-8087
Practice Address - Fax:630-585-8024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-02
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-002778332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL310260Medicare UPIN