Provider Demographics
NPI:1265505077
Name:NORTHEASTERN FOOT & ANKLE SPECIALISTS, PC
Entity Type:Organization
Organization Name:NORTHEASTERN FOOT & ANKLE SPECIALISTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANAS
Authorized Official - Middle Name:
Authorized Official - Last Name:KHOURY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:973-473-6665
Mailing Address - Street 1:235 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-5501
Mailing Address - Country:US
Mailing Address - Phone:973-473-6665
Mailing Address - Fax:973-471-7308
Practice Address - Street 1:235 MAIN AVE
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-5501
Practice Address - Country:US
Practice Address - Phone:973-473-6665
Practice Address - Fax:973-471-7308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00272000213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0011533Medicaid
NJU93925Medicare UPIN
NJ0011533Medicaid
NJ097552Medicare PIN