Provider Demographics
NPI:1780801548
Name:EDGEWATER BEACH FOOT AND ANKLE CENTER, P.C.
Entity type:Organization
Organization Name:EDGEWATER BEACH FOOT AND ANKLE CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BENITA
Authorized Official - Middle Name:J
Authorized Official - Last Name:KAPNICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-271-0807
Mailing Address - Street 1:800 AUSTIN ST STE 508
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3445
Mailing Address - Country:US
Mailing Address - Phone:773-271-0807
Mailing Address - Fax:484-723-7350
Practice Address - Street 1:5331 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-2531
Practice Address - Country:US
Practice Address - Phone:773-271-0807
Practice Address - Fax:484-723-7350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016002871213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL480021114OtherMEDICARE PALMETTO
IL60000959OtherBLUE CROSS BLUE SHIELD
IL016002871Medicaid