Provider Demographics
NPI:1437607769
Name:DENISE J PETENZI, DPM, LLC
Entity Type:Organization
Organization Name:DENISE J PETENZI, DPM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETENZI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:312-505-0156
Mailing Address - Street 1:2644 N WAYNE AVE
Mailing Address - Street 2:UNIT C
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1222
Mailing Address - Country:US
Mailing Address - Phone:312-505-0156
Mailing Address - Fax:773-529-3911
Practice Address - Street 1:2644 N WAYNE AVE APT C
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-6783
Practice Address - Country:US
Practice Address - Phone:312-505-0156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-15
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005107213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005107Medicaid
ILU98422Medicare UPIN