Provider Demographics
NPI:1396773693
Name:DALY, KATHLEEN MARIE (DPM)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:DALY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 N HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60707-3119
Mailing Address - Country:US
Mailing Address - Phone:773-239-8660
Mailing Address - Fax:773-239-9087
Practice Address - Street 1:10431 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-2017
Practice Address - Country:US
Practice Address - Phone:773-239-8660
Practice Address - Fax:773-239-9087
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL01600440213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL60010788OtherBLUE CROSS BLUE SHIELD
IL60010788OtherBLUE CROSS BLUE SHIELD
IL480013157Medicare PIN
ILT97980Medicare UPIN
IL5403150001Medicare NSC
IL956940Medicare PIN