1104085083 NPI number — CENTER FOR RECONSTRUCTIVE SURGERY OF THE FOOT ANKLE & LEG, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104085083 NPI number — CENTER FOR RECONSTRUCTIVE SURGERY OF THE FOOT ANKLE & LEG, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTER FOR RECONSTRUCTIVE SURGERY OF THE FOOT ANKLE & LEG, PLLC
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:
6
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:
1104085083
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13855 W 9 MILE RD
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
OAK PARK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48237-2775
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-545-4110
Provider Business Mailing Address Fax Number:
248-544-2502

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13855 W 9 MILE RD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
OAK PARK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48237-2775
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-545-4110
Provider Business Practice Location Address Fax Number:
248-544-2502
Provider Enumeration Date:
06/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SIDDIQUE
Authorized Official First Name:
SEHRA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
248-545-4110

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  5901002201 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0P61440 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0P61440 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4856319350 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 6140810001 . This is a "MEDICARE NGS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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