Provider Demographics
NPI:1427219500
Name:A GOLD COAST FOOT CLINIC, LTD.
Entity type:Organization
Organization Name:A GOLD COAST FOOT CLINIC, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:II
Authorized Official - Credentials:DPM
Authorized Official - Phone:312-266-7404
Mailing Address - Street 1:845 N MICHIGAN AVE
Mailing Address - Street 2:915W
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2252
Mailing Address - Country:US
Mailing Address - Phone:312-266-7404
Mailing Address - Fax:312-494-9110
Practice Address - Street 1:845 N MICHIGAN AVE
Practice Address - Street 2:915W
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2252
Practice Address - Country:US
Practice Address - Phone:312-266-7404
Practice Address - Fax:312-494-9110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-20
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004014213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT80687Medicare UPIN