Provider Demographics
NPI:1245610476
Name:RECONSTRUCTIVE FOOT AND ANKLE INSTITUTE, LLC
Entity Type:Organization
Organization Name:RECONSTRUCTIVE FOOT AND ANKLE INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:MICHAELS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:301-797-8554
Mailing Address - Street 1:1150 PROFESSIONAL CT
Mailing Address - Street 2:SUITE C
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-4100
Mailing Address - Country:US
Mailing Address - Phone:301-797-8554
Mailing Address - Fax:301-797-9228
Practice Address - Street 1:2100 OLD FARM DR
Practice Address - Street 2:SUITE D
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-9494
Practice Address - Country:US
Practice Address - Phone:301-418-6014
Practice Address - Fax:301-797-8554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01333332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD403918100Medicaid
MD403918100Medicaid