Basic Information
| Provider Information | |||||||||
| NPI: | 1134158397 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE FOOT & ANKLE INSTITUTE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 754 SOUTH MAIN | ||||||||
| Address2: | STE 3 | ||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356282671 | ||||||||
| FaxNumber: | 4356341601 | ||||||||
| Practice Location | |||||||||
| Address1: | 754 SOUTH MAIN | ||||||||
| Address2: | STE 3 | ||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356282671 | ||||||||
| FaxNumber: | 4356341601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2006 | ||||||||
| LastUpdateDate: | 01/27/2020 | ||||||||
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| AuthorizedOfficialLastName: | REBER | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4356282671 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
| NPICertificationDate: | 01/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 103085 | UT | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 100506164 | 05 | NV | MEDICAID | NV2504 | 01 | NV | BCBS FEDERAL | OTHER |