Provider Demographics
NPI:1265942080
Name:PERFORMANCE PODIATRY PARTNERS, LLC
Entity type:Organization
Organization Name:PERFORMANCE PODIATRY PARTNERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SUPNA
Authorized Official - Middle Name:
Authorized Official - Last Name:REILLY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:508-259-8466
Mailing Address - Street 1:2120 N WINCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-3915
Mailing Address - Country:US
Mailing Address - Phone:508-259-8466
Mailing Address - Fax:
Practice Address - Street 1:4805 N CLAREMONT AVE
Practice Address - Street 2:COMMERCIAL UNIT 1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625
Practice Address - Country:US
Practice Address - Phone:312-579-3150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-06
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports MedicineGroup - Single Specialty