Provider Demographics
NPI:1023086113
Name:ELITE FOOT AND ANKLE SURGICAL SPECIALISTS
Entity type:Organization
Organization Name:ELITE FOOT AND ANKLE SURGICAL SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:J
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:602-995-1169
Mailing Address - Street 1:1002 E MCDOWELL RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2625
Mailing Address - Country:US
Mailing Address - Phone:602-262-2663
Mailing Address - Fax:602-258-3008
Practice Address - Street 1:1002 E MCDOWELL RD
Practice Address - Street 2:SUITE A
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2625
Practice Address - Country:US
Practice Address - Phone:602-262-2663
Practice Address - Fax:602-258-3008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ00571213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ797897Medicaid
AZU95186Medicare UPIN
AZ84408Medicare ID - Type Unspecified