Provider Demographics
NPI:1881745388
Name:ADVANCED PODIATRY
Entity type:Organization
Organization Name:ADVANCED PODIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:GAGNON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:773-229-8200
Mailing Address - Street 1:7355 ARCHER AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:SUMMIT
Mailing Address - State:IL
Mailing Address - Zip Code:60501-1225
Mailing Address - Country:US
Mailing Address - Phone:773-229-8200
Mailing Address - Fax:773-229-9752
Practice Address - Street 1:7355 ARCHER AVE
Practice Address - Street 2:SUITE D
Practice Address - City:SUMMIT
Practice Address - State:IL
Practice Address - Zip Code:60501-1225
Practice Address - Country:US
Practice Address - Phone:773-229-8200
Practice Address - Fax:773-229-9752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-13
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1319300001Medicare NSC