Provider Demographics
NPI:1932395464
Name:THE INSTITUTE OF FOOT & ANKLE RECONSTRUCTIVE SURGERY, LLC
Entity Type:Organization
Organization Name:THE INSTITUTE OF FOOT & ANKLE RECONSTRUCTIVE SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AHMAD
Authorized Official - Middle Name:KASSEM
Authorized Official - Last Name:ELSAMAD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:219-488-6409
Mailing Address - Street 1:9120 DOUBLETREE DR S
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-7655
Mailing Address - Country:US
Mailing Address - Phone:219-779-9407
Mailing Address - Fax:219-779-9403
Practice Address - Street 1:9239 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7046
Practice Address - Country:US
Practice Address - Phone:219-736-1010
Practice Address - Fax:219-736-1090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07001024A213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200824830AMedicaid
IN6157100001Medicare NSC
IN253410Medicare PIN