Provider Demographics
NPI:1710231584
Name:ASG ONSITE PODIATRY OF IL 1 PC
Entity Type:Organization
Organization Name:ASG ONSITE PODIATRY OF IL 1 PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YEV
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:773-770-0140
Mailing Address - Street 1:10 S RIVERSIDE PLZ
Mailing Address - Street 2:STE 19 EAST
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-3728
Mailing Address - Country:US
Mailing Address - Phone:773-770-0140
Mailing Address - Fax:312-277-6757
Practice Address - Street 1:10 S RIVERSIDE PLZ
Practice Address - Street 2:STE 19 EAST
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-3728
Practice Address - Country:US
Practice Address - Phone:773-770-0140
Practice Address - Fax:312-277-6757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty