Healthcare Provider Details

I. General information

NPI: 1336835875
Provider Name (Legal Business Name): FOOT & ANKLE INSTITUTE OF SPORTS MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2023
Last Update Date: 02/11/2025
Certification Date: 02/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 STONE ST STE 3
PORT HURON MI
48060-3569
US

IV. Provider business mailing address

1107 STONE ST STE 3
PORT HURON MI
48060-3569
US

V. Phone/Fax

Practice location:
  • Phone: 810-204-4494
  • Fax: 810-479-9640
Mailing address:
  • Phone: 810-204-4494
  • Fax: 810-479-9640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: RACHELLE RANDALL
Title or Position: COO
Credential: DPM
Phone: 810-650-7113