Provider Demographics
NPI:1205023033
Name:FOOT AND ANKLE SPECIALTY CLINIC
Entity Type:Organization
Organization Name:FOOT AND ANKLE SPECIALTY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUMMER
Authorized Official - Middle Name:
Authorized Official - Last Name:TOURFA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-846-9717
Mailing Address - Street 1:5525 SCHAEFER RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3253
Mailing Address - Country:US
Mailing Address - Phone:313-846-9717
Mailing Address - Fax:313-846-9805
Practice Address - Street 1:5525 SCHAEFER RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3253
Practice Address - Country:US
Practice Address - Phone:313-846-9717
Practice Address - Fax:313-846-9805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002122213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4858213650OtherBLUE CROSS BLUE SHIELD
MI4858213650OtherBLUECARE NETWORK
MI4849095Medicaid
MIV08252Medicare UPIN
MI0P27470Medicare PIN
MI4858213650OtherBLUE CROSS BLUE SHIELD