Provider Demographics
NPI:1174630149
Name:UNIVERSITY FOOT AND ANKLE INSTITUTE A PODIATRIC SURGICAL CENTER
Entity Type:Organization
Organization Name:UNIVERSITY FOOT AND ANKLE INSTITUTE A PODIATRIC SURGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER PODIATRY
Authorized Official - Prefix:MR
Authorized Official - First Name:BABAK
Authorized Official - Middle Name:
Authorized Official - Last Name:BARAVARIAN
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 1:150 N ROBERTSON BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211
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:2006-08-24
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4186213E00000X
CAE4431213ES0103X
CAE3141213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV00110Medicare UPIN
WE4186AMedicare ID - Type Unspecified
CA4759290005Medicare NSC
CAW16343AMedicare PIN
U74434Medicare UPIN
CAW16343Medicare UPIN