Provider Demographics
NPI:1770235525
Name:PODIATRY OF GREATER CHICAGO, PLLC
Entity Type:Organization
Organization Name:PODIATRY OF GREATER CHICAGO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIJANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRKOVIC
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:262-960-0516
Mailing Address - Street 1:6220 W IRVING PARK RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-3070
Mailing Address - Country:US
Mailing Address - Phone:262-960-0516
Mailing Address - Fax:
Practice Address - Street 1:1406 S CHESTNUT DR
Practice Address - Street 2:
Practice Address - City:MT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-4520
Practice Address - Country:US
Practice Address - Phone:708-320-1510
Practice Address - Fax:773-847-4467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1588075584Medicaid
FM6864638OtherDEA