Provider Demographics
NPI:1891040424
Name:CHICAGO FOOT & ANKLE CLINIC
Entity Type:Organization
Organization Name:CHICAGO FOOT & ANKLE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHAWNI
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-376-7200
Mailing Address - Street 1:2801 W CERMAK RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-3513
Mailing Address - Country:US
Mailing Address - Phone:773-376-7200
Mailing Address - Fax:773-376-9211
Practice Address - Street 1:2801 W CERMAK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-3513
Practice Address - Country:US
Practice Address - Phone:773-376-7200
Practice Address - Fax:773-376-9211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004154213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL773030Medicare UPIN