Provider Demographics
NPI:1154626661
Name:MONTICELLO PODIATRY LLC
Entity Type:Organization
Organization Name:MONTICELLO PODIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:DR
Authorized Official - First Name:MURTUZA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEERBHAI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:765-420-2850
Mailing Address - Street 1:101 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IN
Mailing Address - Zip Code:47960
Mailing Address - Country:US
Mailing Address - Phone:765-420-2850
Mailing Address - Fax:
Practice Address - Street 1:101 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IN
Practice Address - Zip Code:47960-2110
Practice Address - Country:US
Practice Address - Phone:765-420-2850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-13
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN#07001110A261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty