Provider Demographics
NPI:1528257441
Name:PODIATRY & SPORTS CENTER, LTD.
Entity type:Organization
Organization Name:PODIATRY & SPORTS CENTER, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:O'BRIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:630-529-6634
Mailing Address - Street 1:10 N ROSELLE RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172-1592
Mailing Address - Country:US
Mailing Address - Phone:630-529-6634
Mailing Address - Fax:630-529-6760
Practice Address - Street 1:10 N ROSELLE RD
Practice Address - Street 2:SUITE 300
Practice Address - City:ROSELLE
Practice Address - State:IL
Practice Address - Zip Code:60172-1592
Practice Address - Country:US
Practice Address - Phone:630-529-6634
Practice Address - Fax:630-529-6760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060006511213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL266490Medicare PIN