Basic Information
| Provider Information | |||||||||
| NPI: | 1902131840 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAALTZ MOBILE HEALTH SERVICES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WALKS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1226 W TAYLOR ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606074709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122433769 | ||||||||
| FaxNumber: | 3122433840 | ||||||||
| Practice Location | |||||||||
| Address1: | 1226 W TAYLOR ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606074709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122433769 | ||||||||
| FaxNumber: | 3122433840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2009 | ||||||||
| LastUpdateDate: | 09/30/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ZAPPA | ||||||||
| AuthorizedOfficialFirstName: | FRANK | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3122433769 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DPM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 016002513 | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 600204762 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 016002513 | 05 | IL | MEDICAID |