Provider Demographics
NPI:1154591048
Name:GOLD COAST PODIATRY CENTER, LLC
Entity type:Organization
Organization Name:GOLD COAST PODIATRY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:FORTUNEE
Authorized Official - Middle Name:
Authorized Official - Last Name:MASSUDA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:773-752-2111
Mailing Address - Street 1:9933 S WESTERN AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1810
Mailing Address - Country:US
Mailing Address - Phone:773-233-3800
Mailing Address - Fax:773-233-2513
Practice Address - Street 1:1605 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4504
Practice Address - Country:US
Practice Address - Phone:847-424-9888
Practice Address - Fax:847-424-9649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01623607OtherBCBS
IL581450Medicare PIN
IL01623607OtherBCBS
IL4951050002Medicare NSC
CB4982Medicare PIN
IL1154591048Medicare PIN