# BEVERLY PODIATRY CENTER, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1790777118
- **Authorized official:** MRS. FORTUNEE MASSUDA DPM (MEDICAL DIRECTOR/CEO)
- **Authorized official phone:** (773) 445-8700

## Contact information

- **Practice address:** 9933 S WESTERN AVE, SUITE 102, CHICAGO, IL 60643-1810
- **Practice address phone:** (773) 445-8700
- **Practice address fax:** (773) 445-4646
- **Mailing address:** 9933 S WESTERN AVE, SUITE 102, CHICAGO, IL 60643-1810
- **Mailing address phone:** (773) 445-8700
- **Mailing address fax:** (773) 445-4646

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 213E00000X | Podiatrist | — | IL | — |
| 213EP0504X | Public Medicine Podiatrist | — | IL | — |
| 213EP1101X | Primary Podiatric Medicine Podiatrist | — | IL | — |
| 213ES0103X | Foot & Ankle Surgery Podiatrist | — | IL | Yes |
| 213ES0131X | Foot Surgery Podiatrist | — | IL | — |

## Other

- **Enumeration date:** 08/22/2005
- **Last updated:** 11/12/2009