Provider Demographics
NPI:1497958946
Name:NORTHEAST FOOT & ANKLE CLINIC INC
Entity Type:Organization
Organization Name:NORTHEAST FOOT & ANKLE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:WORPELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:260-416-0070
Mailing Address - Street 1:2510 E DUPONT RD
Mailing Address - Street 2:STE. 234
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1600
Mailing Address - Country:US
Mailing Address - Phone:260-416-0070
Mailing Address - Fax:260-416-0017
Practice Address - Street 1:2510 E DUPONT RD
Practice Address - Street 2:STE. 234
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1600
Practice Address - Country:US
Practice Address - Phone:260-416-0070
Practice Address - Fax:260-416-0017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000957A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN4868080001Medicare NSC
INT02239Medicare UPIN
200170Medicare PIN