Provider Demographics
NPI:1881026185
Name:MICHIGAN AVE PODIATRY LLC 1
Entity Type:Organization
Organization Name:MICHIGAN AVE PODIATRY LLC 1
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STOCKHOLDER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:EERNISSE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:312-701-0770
Mailing Address - Street 1:30 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 720
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60602-3809
Mailing Address - Country:US
Mailing Address - Phone:312-701-0770
Mailing Address - Fax:312-701-0705
Practice Address - Street 1:30 N MICHIGAN AVE
Practice Address - Street 2:SUITE 720
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3809
Practice Address - Country:US
Practice Address - Phone:312-701-0770
Practice Address - Fax:312-701-0705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-08
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004918213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty