Provider Demographics
NPI:1720501257
Name:PODIATRY SERVICE OF AMERICA CORP
Entity Type:Organization
Organization Name:PODIATRY SERVICE OF AMERICA CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:POTACH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:847-215-1525
Mailing Address - Street 1:31 WEST DUNDEE
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090
Mailing Address - Country:US
Mailing Address - Phone:847-215-1525
Mailing Address - Fax:847-215-7682
Practice Address - Street 1:31 W DUNDEE RD
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:IL
Practice Address - Zip Code:60090-4863
Practice Address - Country:US
Practice Address - Phone:847-215-1525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-17
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty