Provider Demographics
NPI:1760686075
Name:FOOTWISE PODIATRY, LTD.
Entity Type:Organization
Organization Name:FOOTWISE PODIATRY, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARTINO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:847-837-1076
Mailing Address - Street 1:1324 KETTERING RD
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-5364
Mailing Address - Country:US
Mailing Address - Phone:847-837-1076
Mailing Address - Fax:847-837-9228
Practice Address - Street 1:1324 KETTERING RD
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-5364
Practice Address - Country:US
Practice Address - Phone:847-837-1076
Practice Address - Fax:847-837-9228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2012-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004178213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL600-01724OtherBCBS OF ILLINOIS
IL600-01724OtherBCBS OF ILLINOIS
ILT39230Medicare UPIN