Provider Demographics
NPI:1104085083
Name:CENTER FOR RECONSTRUCTIVE SURGERY OF THE FOOT ANKLE & LEG, PLLC
Entity type:Organization
Organization Name:CENTER FOR RECONSTRUCTIVE SURGERY OF THE FOOT ANKLE & LEG, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SEHRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-545-4110
Mailing Address - Street 1:13855 W 9 MILE RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-2775
Mailing Address - Country:US
Mailing Address - Phone:248-545-4110
Mailing Address - Fax:248-544-2502
Practice Address - Street 1:13855 W 9 MILE RD
Practice Address - Street 2:SUITE C
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-2775
Practice Address - Country:US
Practice Address - Phone:248-545-4110
Practice Address - Fax:248-544-2502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2012-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002201213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0P61440OtherAETNA
MI0P61440Medicaid
MI4856319350OtherBCBSM
MI6140810001OtherMEDICARE NGS
0P61440OtherAETNA