Provider Demographics
NPI:1841389830
Name:LOGAN SQUARE FOOT CENTER
Entity Type:Organization
Organization Name:LOGAN SQUARE FOOT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GARRY
Authorized Official - Middle Name:S
Authorized Official - Last Name:ISENSTADT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:773-772-4440
Mailing Address - Street 1:2831 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-7403
Mailing Address - Country:US
Mailing Address - Phone:773-772-4440
Mailing Address - Fax:773-772-4461
Practice Address - Street 1:2831 N MILWAUKEE AVE.
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-7403
Practice Address - Country:US
Practice Address - Phone:773-772-4440
Practice Address - Fax:773-772-4461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT36912Medicare UPIN