MEDICARE: FOOT & ANKLE SURGICAL GROUP, LLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	38610	NV
2	213ES0103X	Foot & Ankle Surgery Podiatrist

General Provider Information

NPI Number	:	1194938936
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOOT & ANKLE SURGICAL GROUP, LLP

Provider Business Mailing Address
First Line	:	129 W LAKE MEAD PKWY
Second Line	:	#B-18
City	:	HENDERSON
State	:	NV
Zip	:	89015-7055
Country	:	US
Telephone Number	:	702-564-8022
Fax Number	:	702-558-1522

Provider Business Practice Location Address
First Line	:	999 ADAMS BLVD
Second Line	:	#104
City	:	BOULDER CITY
State	:	NV
Zip	:	89005-2244
Country	:	US
Telephone Number	:	702-293-0151
Fax Number	:	702-456-6688

Authorized Official
Title or Position	:	GENERAL PARTNER
Name	:	DOUGLAS S STACEY
Credential	:	DPM
Telephone Number	:	702-456-3668

Provider Enumeration Date	:	05/08/2007
Last Update Date	:	10/06/2009

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