Provider Demographics
NPI:1639440944
Name:PEACHTREE PODIATRY LLC
Entity Type:Organization
Organization Name:PEACHTREE PODIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:L
Authorized Official - Last Name:PEACH
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:773-372-1191
Mailing Address - Street 1:3534 W PALMER ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-5699
Mailing Address - Country:US
Mailing Address - Phone:773-372-1191
Mailing Address - Fax:
Practice Address - Street 1:3534 W PALMER ST APT 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5699
Practice Address - Country:US
Practice Address - Phone:773-372-1191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005323213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005323OtherLICENSE