Provider Demographics
NPI:1831886209
Name:SOUTH SHORE FOOT AND ANKLE WELLNESS CENTER LLC
Entity type:Organization
Organization Name:SOUTH SHORE FOOT AND ANKLE WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:AKERELE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:773-978-2100
Mailing Address - Street 1:2223 E 79TH STREET, CHICAGO , IL. 60649
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60649
Mailing Address - Country:US
Mailing Address - Phone:773-978-2100
Mailing Address - Fax:
Practice Address - Street 1:2223 E 79TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-5016
Practice Address - Country:US
Practice Address - Phone:773-978-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-18
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric