Provider Demographics
NPI:1669644548
Name:BANDYK PODIATRY
Entity type:Organization
Organization Name:BANDYK PODIATRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JON
Authorized Official - Last Name:BANDYK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-474-1900
Mailing Address - Street 1:18503 TORRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438
Mailing Address - Country:US
Mailing Address - Phone:708-474-1900
Mailing Address - Fax:708-474-1037
Practice Address - Street 1:18503 TORRENCE AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:IL
Practice Address - Zip Code:60438
Practice Address - Country:US
Practice Address - Phone:708-474-1900
Practice Address - Fax:708-474-1037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004010213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004010Medicaid
4800148821OtherRAILROAD MEDICARE
IL6000 1 555OtherBLUECROSS BLUESHIELD
4800148821OtherRAILROAD MEDICARE
IL6000 1 555OtherBLUECROSS BLUESHIELD