Provider Demographics
NPI:1912014986
Name:UNIVERSITY FOOT AND ANKLE INSTITUTE A PODIATRIC SURGICAL CENTER
Entity Type:Organization
Organization Name:UNIVERSITY FOOT AND ANKLE INSTITUTE A PODIATRIC SURGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RCMO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:REYZELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:510-581-1484
Mailing Address - Street 1:2121 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403
Mailing Address - Country:US
Mailing Address - Phone:310-828-0011
Mailing Address - Fax:310-828-2001
Practice Address - Street 1:2121 WILSHIRE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403
Practice Address - Country:US
Practice Address - Phone:310-828-0011
Practice Address - Fax:310-828-2001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4186213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00054144OtherMEDICARE RAILROAD
CA4759290005Medicare NSC
U74434Medicare UPIN
CA4759290010Medicare NSC
CAW16343Medicare PIN
CA4759290003Medicare NSC
CA4759290006Medicare NSC
CAP00054144OtherMEDICARE RAILROAD
WE4186AMedicare ID - Type Unspecified
CA4759290002Medicare NSC
CAW16343AMedicare PIN
CAWE4186AMedicare PIN