Life Gate Pharmacy LLC

Primary specialty

Foot & Ankle Surgery PodiatristTaxonomy code 213ES0103X

License

016003225 Issued in IL

Legal business name

LIFE GATE PHARMACY LLC

Practice address

5241 S Cicero Ave
Chicago, IL 60632

Phone

(708) 557-3155

Fax

(773) 284-6431

NPI assigned

Mar 25, 2014

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Ms. Michelle Herzog

Title

Owner

Phone

(708) 557-3155

Specialties & licenses 2

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1395705600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1537142400000",
    "number": "1558788760",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8559 W 121ST ST",
            "city": "PALOS PARK",
            "state": "IL",
            "postal_code": "604641230",
            "telephone_number": "708-557-3155",
            "fax_number": "727-474-9067"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5241 S CICERO AVE",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "60632",
            "telephone_number": "708-557-3155",
            "fax_number": "773-284-6431"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "8559 W 121st St",
            "address_purpose": "LOCATION",
            "city": "Palos Park",
            "state": "IL",
            "postal_code": "604641230",
            "country_code": "US",
            "telephone_number": "708-557-3155",
            "fax_number": "727-474-9067",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "LIFE GATE PHARMACY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-03-25",
        "last_updated": "2018-09-17",
        "status": "A",
        "authorized_official_last_name": "HERZOG",
        "authorized_official_first_name": "MICHELLE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "708-557-3155",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "207P00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Emergency Medicine",
            "state": "IL",
            "license": "036059796",
            "primary": false
        },
        {
            "code": "213ES0103X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Podiatrist, Foot & Ankle Surgery",
            "state": "IL",
            "license": "016003225",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Foot & Ankle Surgery Podiatrist in Chicago, IL
• Providers in Chicago, IL by specialty
• Foot & Ankle Surgery Podiatrist in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 17, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.