Provider Demographics
NPI:1811171630
Name:BRIAN CHIARAMONTE FOOT AND ANKLE CENTER OF BRIDGEPORT
Entity type:Organization
Organization Name:BRIAN CHIARAMONTE FOOT AND ANKLE CENTER OF BRIDGEPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:CHIARAMONTE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:773-579-1440
Mailing Address - Street 1:3303 S HALSTED ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-6705
Mailing Address - Country:US
Mailing Address - Phone:773-579-1440
Mailing Address - Fax:773-579-0227
Practice Address - Street 1:3303 S HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-6705
Practice Address - Country:US
Practice Address - Phone:773-579-1440
Practice Address - Fax:773-579-0227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004502213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4320920001Medicare NSC