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Organization
FOOTCO ORTHOPEDIC
Active
Organization
FOOTCO ORTHOPEDIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TIM PORCELLI LC PED (DIRECTOR, CHIEF CLINICIAN)
(312) 409-2175
Entity
Organization
Contact information
Practice address
3723 N SOUTHPORT AVE, CHICAGO, IL 60613-3718
(312) 409-2175
Mailing address
PO BOX 13377, CHICAGO, IL 60613-0377
Taxonomy
Speciality
Code
Description
License number
State
332BC3200X
Customized Equipment (DME)
Primary
212.000115
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1670909
BLUE CROSS
IL
Enumeration date
05/28/2008
Last updated
05/28/2008
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