Basic Information
| Provider Information | |||||||||
| NPI: | 1437479839 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIMONOVICH | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 259 E ERIE ST STE 2230 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606113370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126956800 | ||||||||
| FaxNumber: | 3129268267 | ||||||||
| Practice Location | |||||||||
| Address1: | 259 E ERIE ST | ||||||||
| Address2: | SUITE 2230 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129266000 | ||||||||
| FaxNumber: | 3129268267 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2010 | ||||||||
| LastUpdateDate: | 07/12/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 016005484 | IL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213E00000X | 016005484 | IL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.