Provider Demographics
NPI:1356633754
Name:RECONSTRUCTIVE FOOT & ANKLE INSTITUTE, LLC
Entity Type:Organization
Organization Name:RECONSTRUCTIVE FOOT & ANKLE INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:MICHAELS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM, MS
Authorized Official - Phone:301-797-8554
Mailing Address - Street 1:PO BOX 269
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21705-0269
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:301-797-9228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-04
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U90774Medicare UPIN