Provider Demographics
NPI:1801198114
Name:MICHAEL A WALSH DPM PC
Entity Type:Organization
Organization Name:MICHAEL A WALSH DPM PC
Other - Org Name:MICHAEL WALSH, DPM, PC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALSH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:847-455-8148
Mailing Address - Street 1:9806 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60131-2679
Mailing Address - Country:US
Mailing Address - Phone:312-718-4136
Mailing Address - Fax:
Practice Address - Street 1:9806 GRAND AVE
Practice Address - Street 2:
Practice Address - City:FRANKLIN PARK
Practice Address - State:IL
Practice Address - Zip Code:60131-2679
Practice Address - Country:US
Practice Address - Phone:312-718-4136
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-19
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004256213E00000X
213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL906900Medicare UPIN