Basic Information
| Provider Information | |||||||||
| NPI: | 1265726830 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOOT & ANKLE SURGICAL ASSOCIATES LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 54 S DEAN STREET | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187283334 | ||||||||
| FaxNumber: | 7187773180 | ||||||||
| Practice Location | |||||||||
| Address1: | 54 S DEAN STREET | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187283334 | ||||||||
| FaxNumber: | 7187773180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2011 | ||||||||
| LastUpdateDate: | 06/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | PERSICH | ||||||||
| AuthorizedOfficialFirstName: | GIANNI | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7187283334 | ||||||||
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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 | MD00304200 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01360874 | 05 | NY | MEDICAID |