Provider Demographics
NPI:1649597139
Name:FOOT & ANKLE RECONSTRUCTION ASSOCIATES LLC
Entity Type:Organization
Organization Name:FOOT & ANKLE RECONSTRUCTION ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:T
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:863-385-5525
Mailing Address - Street 1:3200 MEDICAL WAY
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33870-5419
Mailing Address - Country:US
Mailing Address - Phone:863-385-5525
Mailing Address - Fax:863-385-7312
Practice Address - Street 1:3200 MEDICAL WAY
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-5419
Practice Address - Country:US
Practice Address - Phone:863-385-5525
Practice Address - Fax:863-385-7312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-23
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3400213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6364940001Medicare NSC