Provider Demographics
NPI:1821289828
Name:KENNETH INDAHL
Entity Type:Organization
Organization Name:KENNETH INDAHL
Other - Org Name:ALLAIRE FOOT & ANKLE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:INDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:732-528-8223
Mailing Address - Street 1:2399 HIGHWAY 34
Mailing Address - Street 2:SUITE A6
Mailing Address - City:MANASQUAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08736-1500
Mailing Address - Country:US
Mailing Address - Phone:732-528-8223
Mailing Address - Fax:732-528-7057
Practice Address - Street 1:2399 HIGHWAY 34
Practice Address - Street 2:SUITE A6
Practice Address - City:MANASQUAN
Practice Address - State:NJ
Practice Address - Zip Code:08736-1500
Practice Address - Country:US
Practice Address - Phone:732-528-8223
Practice Address - Fax:732-528-7057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00100900213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ022471Medicare PIN
NJ0584820001Medicare NSC