Provider Demographics
NPI:1144497694
Name:ADVANCED FOOT & ANKLE CARE CENTER PLLC
Entity type:Organization
Organization Name:ADVANCED FOOT & ANKLE CARE CENTER PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ISSAM
Authorized Official - Middle Name:N
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:248-888-9500
Mailing Address - Street 1:24230 KARIM BLVD
Mailing Address - Street 2:STE 140
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-2953
Mailing Address - Country:US
Mailing Address - Phone:248-888-9500
Mailing Address - Fax:248-888-9504
Practice Address - Street 1:24230 KARIM BLVD
Practice Address - Street 2:STE 140
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-2953
Practice Address - Country:US
Practice Address - Phone:248-888-9500
Practice Address - Fax:248-888-9504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002177213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6164970001Medicare NSC