Provider Demographics
NPI:1790351757
Name:ADDISON PODIATRY CENTER PLLC
Entity Type:Organization
Organization Name:ADDISON PODIATRY CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF PODIATRIC MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:630-205-4557
Mailing Address - Street 1:198 SUNNYBROOK RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-6477
Mailing Address - Country:US
Mailing Address - Phone:630-205-4557
Mailing Address - Fax:
Practice Address - Street 1:1250 W LAKE ST
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:IL
Practice Address - Zip Code:60101-5744
Practice Address - Country:US
Practice Address - Phone:630-543-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty