Provider Demographics
NPI:1164887048
Name:UNIVERSITY FOOT & ANKLE INSTITUTE PODIACTRIC SURGICAL CENTER
Entity Type:Organization
Organization Name:UNIVERSITY FOOT & ANKLE INSTITUTE PODIACTRIC SURGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRISKIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:310-828-0011
Mailing Address - Street 1:2121 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403
Mailing Address - Country:US
Mailing Address - Phone:310-828-0011
Mailing Address - Fax:310-828-2001
Practice Address - Street 1:5230 PACIFIC CONCOURSE DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045
Practice Address - Country:US
Practice Address - Phone:310-828-0011
Practice Address - Fax:310-828-2001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3141213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16343Medicare PIN