Provider Demographics
NPI:1730442559
Name:RETINA INSTITUTE OF INDIANA SURGERY CENTER, LLC
Entity type:Organization
Organization Name:RETINA INSTITUTE OF INDIANA SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:
Authorized Official - First Name:GOHAR
Authorized Official - Middle Name:AZAM
Authorized Official - Last Name:SALAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-483-9500
Mailing Address - Street 1:11192 DIEBOLD RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-9662
Mailing Address - Country:US
Mailing Address - Phone:260-483-9500
Mailing Address - Fax:260-483-9511
Practice Address - Street 1:11192 DIEBOLD RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-9662
Practice Address - Country:US
Practice Address - Phone:260-483-9500
Practice Address - Fax:260-483-9511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-18
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058885A207W00000X
IN13 012741 1261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty