Provider Demographics
NPI:1801142740
Name:BEB PODIATRY SC
Entity type:Organization
Organization Name:BEB PODIATRY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BACARDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-922-4315
Mailing Address - Street 1:36 DEER POINT DR
Mailing Address - Street 2:
Mailing Address - City:HAWTHORN WOODS
Mailing Address - State:IL
Mailing Address - Zip Code:60047-8010
Mailing Address - Country:US
Mailing Address - Phone:847-922-4315
Mailing Address - Fax:847-725-2155
Practice Address - Street 1:36 DEER POINT DR
Practice Address - Street 2:
Practice Address - City:HAWTHORN WOODS
Practice Address - State:IL
Practice Address - Zip Code:60047-8010
Practice Address - Country:US
Practice Address - Phone:847-922-4315
Practice Address - Fax:847-725-2155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-30
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016.003631213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty