Provider Demographics
NPI:1396968053
Name:PODIATRIC MANAGEMENT SYSTEMS LLC
Entity type:Organization
Organization Name:PODIATRIC MANAGEMENT SYSTEMS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICE
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-372-1160
Mailing Address - Street 1:70 E LAKE ST STE 1102
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7499
Mailing Address - Country:US
Mailing Address - Phone:312-372-1160
Mailing Address - Fax:312-372-3346
Practice Address - Street 1:765 ELA RD
Practice Address - Street 2:
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-2385
Practice Address - Country:US
Practice Address - Phone:847-540-9949
Practice Address - Fax:847-540-9971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213ES0103X
213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN90001026OtherBCBS PROVIDER NUMBER
IL1621423OtherBCBS PROVIDER NUMBER