Provider Demographics
NPI:1124286927
Name:FOOTCO ORTHOPEDIC
Entity type:Organization
Organization Name:FOOTCO ORTHOPEDIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, CHIEF CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:PORCELLI
Authorized Official - Suffix:
Authorized Official - Credentials:LC PED
Authorized Official - Phone:312-409-2175
Mailing Address - Street 1:PO BOX 13377
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-0377
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3723 N SOUTHPORT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-3718
Practice Address - Country:US
Practice Address - Phone:312-409-2175
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL212.000115332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1670909OtherBLUE CROSS