Provider Demographics
NPI:1124054325
Name:IN BALANCE PODIATRY, LTD.
Entity type:Organization
Organization Name:IN BALANCE PODIATRY, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:SEDORY
Authorized Official - Suffix:
Authorized Official - Credentials:D P M
Authorized Official - Phone:708-352-5121
Mailing Address - Street 1:PO BOX 2382
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-8482
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:132 N CATHERINE AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-1828
Practice Address - Country:US
Practice Address - Phone:708-352-5121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003538213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016003538Medicaid
IL4034180001Medicare NSC
K28257Medicare PIN
IL480028476Medicare PIN
K28256Medicare PIN