Provider Demographics
NPI:1194938936
Name:FOOT & ANKLE SURGICAL GROUP, LLP
Entity type:Organization
Organization Name:FOOT & ANKLE SURGICAL GROUP, LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:S
Authorized Official - Last Name:STACEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:702-456-3668
Mailing Address - Street 1:129 W LAKE MEAD PKWY
Mailing Address - Street 2:#B-18
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89015-7055
Mailing Address - Country:US
Mailing Address - Phone:702-564-8022
Mailing Address - Fax:702-558-1522
Practice Address - Street 1:999 ADAMS BLVD
Practice Address - Street 2:#104
Practice Address - City:BOULDER CITY
Practice Address - State:NV
Practice Address - Zip Code:89005-2244
Practice Address - Country:US
Practice Address - Phone:702-293-0151
Practice Address - Fax:702-456-6688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
213ES0103X
NV38610332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV5277230003Medicare NSC
NVDB6830Medicare PIN
NVV38604Medicare PIN
NV5277230002Medicare NSC
NV5277230001Medicare NSC