1255496352 NPI number — RECONSTRUCTIVE FOOT & ANKLE SPECIALISTS, LLC

Table of content: (NPI 1255496352)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255496352 NPI number — RECONSTRUCTIVE FOOT & ANKLE SPECIALISTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RECONSTRUCTIVE FOOT & ANKLE SPECIALISTS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255496352
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 12754
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46866-2754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-969-1950
Provider Business Mailing Address Fax Number:
260-969-0988

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7910 W JEFFERSON BLVD
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46804-4159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-969-1950
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NORTON
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
V
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
260-969-1950

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  07000881A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200847960 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200847960A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com