Provider Demographics
NPI:1336835875
Name:FOOT & ANKLE INSTITUTE OF SPORTS MEDICINE, LLC
Entity type:Organization
Organization Name:FOOT & ANKLE INSTITUTE OF SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:RACHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:810-650-7113
Mailing Address - Street 1:1107 STONE ST STE 3
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3569
Mailing Address - Country:US
Mailing Address - Phone:810-204-4494
Mailing Address - Fax:810-479-9640
Practice Address - Street 1:1107 STONE ST STE 3
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3569
Practice Address - Country:US
Practice Address - Phone:810-204-4494
Practice Address - Fax:810-479-9640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-17
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty