Provider Demographics
NPI:1699198994
Name:PREFERRED PODIATRY GROUP PC
Entity Type:Organization
Organization Name:PREFERRED PODIATRY GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL COUNSEL
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:MICHAEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-504-5002
Mailing Address - Street 1:PO BOX 917
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60065-0917
Mailing Address - Country:US
Mailing Address - Phone:847-504-5000
Mailing Address - Fax:847-504-5015
Practice Address - Street 1:168 N CLINTON ST FL 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60661-1425
Practice Address - Country:US
Practice Address - Phone:847-502-4898
Practice Address - Fax:847-504-5015
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREFERRED PODIATRY GROUP PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-23
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX281333902Medicaid
TX0A6310Medicare PIN