Provider Demographics
NPI:1720253180
Name:BARONS SHOES OF MT GREENWOOD
Entity Type:Organization
Organization Name:BARONS SHOES OF MT GREENWOOD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-238-6100
Mailing Address - Street 1:3101 W 111TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-2205
Mailing Address - Country:US
Mailing Address - Phone:773-238-6100
Mailing Address - Fax:
Practice Address - Street 1:3101 W 111TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-2205
Practice Address - Country:US
Practice Address - Phone:773-238-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0913830001Medicare NSC