Provider Demographics
NPI:1003193814
Name:LAFAYETTE FOOT & ANKLE LLC
Entity Type:Organization
Organization Name:LAFAYETTE FOOT & ANKLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIR
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:260-458-9953
Mailing Address - Street 1:2700 LAFAYETTE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46806-1100
Mailing Address - Country:US
Mailing Address - Phone:260-458-9953
Mailing Address - Fax:260-458-9238
Practice Address - Street 1:2700 LAFAYETTE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46806-1100
Practice Address - Country:US
Practice Address - Phone:260-458-9953
Practice Address - Fax:260-458-9238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-08
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100082090AMedicaid
IN100082090AMedicaid
INU27211Medicare UPIN