Provider Demographics
NPI:1053421180
Name:A BRIDGEPORT FOOT AND ANKLE CLINIC, LTD
Entity type:Organization
Organization Name:A BRIDGEPORT FOOT AND ANKLE CLINIC, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SIDNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WEISER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:312-225-2444
Mailing Address - Street 1:3058 W PETERSON
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659
Mailing Address - Country:US
Mailing Address - Phone:312-225-2444
Mailing Address - Fax:847-674-2113
Practice Address - Street 1:9933 LAWLER AVE
Practice Address - Street 2:SUITE 225
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-3703
Practice Address - Country:US
Practice Address - Phone:312-225-2444
Practice Address - Fax:847-674-2113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004192Medicaid
IL01635040OtherBCBS
IL5366820001Medicare NSC
IL016004192Medicaid