Provider Demographics
NPI:1063690741
Name:NORTHWEST PODIATRY CENTER
Entity type:Organization
Organization Name:NORTHWEST PODIATRY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRYNICZKA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:630-668-8277
Mailing Address - Street 1:705 WARRENVILLE RD
Mailing Address - Street 2:UNIT B
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-6379
Mailing Address - Country:US
Mailing Address - Phone:630-668-8277
Mailing Address - Fax:630-668-3358
Practice Address - Street 1:705 WARRENVILLE RD
Practice Address - Street 2:UNIT B
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-6379
Practice Address - Country:US
Practice Address - Phone:630-668-8277
Practice Address - Fax:630-668-3358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL16-2778332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0374040003Medicare NSC
IL367692Medicare PIN
IL310260Medicare PIN
IL367693Medicare PIN
IL367690Medicare PIN