Provider Demographics
NPI:1609017508
Name:MONTROSE FOOT AND ANKLE LLC
Entity Type:Organization
Organization Name:MONTROSE FOOT AND ANKLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WIKA
Authorized Official - Middle Name:K
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:773-528-4700
Mailing Address - Street 1:1929 W MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1011
Mailing Address - Country:US
Mailing Address - Phone:773-528-4700
Mailing Address - Fax:773-529-5392
Practice Address - Street 1:1929 W MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-1011
Practice Address - Country:US
Practice Address - Phone:773-528-4700
Practice Address - Fax:773-529-5392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-23
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005228Medicaid
6267720001Medicare NSC
ILIL1690Medicare PIN
IL016005228Medicaid