Healthcare Provider Details

I. General information

NPI: 1497958946
Provider Name (Legal Business Name): NORTHEAST FOOT & ANKLE CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 05/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 E DUPONT RD STE. 234
FORT WAYNE IN
46825-1600
US

IV. Provider business mailing address

2510 E DUPONT RD STE. 234
FORT WAYNE IN
46825-1600
US

V. Phone/Fax

Practice location:
  • Phone: 260-416-0070
  • Fax: 260-416-0017
Mailing address:
  • Phone: 260-416-0070
  • Fax: 260-416-0017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number07000957A
License Number StateIN

VIII. Authorized Official

Name: MICHAEL S WORPELL
Title or Position: OWNER PHYSICIAN
Credential: DPM
Phone: 260-416-0070