Healthcare Provider Details

I. General information

NPI: 1164887048
Provider Name (Legal Business Name): UNIVERSITY FOOT AND ANKLE INSTITUTE A PODIATRIC SURGICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2015
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5230 PACIFIC CONCOURSE DR STE 100
LOS ANGELES CA
90045-6279
US

IV. Provider business mailing address

1660 FEEHANVILLE DR STE 450
MOUNT PROSPECT IL
60056-6023
US

V. Phone/Fax

Practice location:
  • Phone: 310-828-0011
  • Fax: 310-828-2001
Mailing address:
  • Phone: 847-627-4920
  • Fax: 224-220-9743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE3141
License Number StateCA

VIII. Authorized Official

Name: ALEXANDER REYZELMAN
Title or Position: RCMO
Credential: DPM
Phone: 415-292-0638