Basic Information
| Provider Information | |||||||||
| NPI: | 1174559215 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RECONSTRUCTIVE FOOT AND ANKLE SURGICAL ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 DORAL DR | ||||||||
| Address2: | |||||||||
| City: | BLACKWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080125424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562329286 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1600 HIGH ST N | ||||||||
| Address2: | |||||||||
| City: | MILLVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 083321922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568259009 | ||||||||
| FaxNumber: | 8568254766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 01/10/2017 | ||||||||
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| AuthorizedOfficialLastName: | RUIZ | ||||||||
| AuthorizedOfficialFirstName: | JOSE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8568259009 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 25MD00234800 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0479397000 | 01 | NJ | AMERIHEALTH HMO | OTHER | 000536893 | 01 | NJ | HIGHMARK BLUE SHIELD | OTHER | 7446802 | 05 | NJ | MEDICAID |