Provider Demographics
NPI:1144695263
Name:AUDEY NASSER PODIATRY, PC
Entity type:Organization
Organization Name:AUDEY NASSER PODIATRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:AUDEY
Authorized Official - Middle Name:
Authorized Official - Last Name:NASSER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:313-969-9775
Mailing Address - Street 1:731 S IL ROUTE 21 STE 140
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-3812
Mailing Address - Country:US
Mailing Address - Phone:313-969-9775
Mailing Address - Fax:
Practice Address - Street 1:731 S IL ROUTE 21 STE 140
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3812
Practice Address - Country:US
Practice Address - Phone:847-295-9300
Practice Address - Fax:847-295-9607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-01
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
213EP1101X, 261QP1100X
MI5901002505213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatricGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI9259001OtherMEDICARE PTAN