MEDICARE: RETINA INSTITUTE OF INDIANA SURGERY CENTER, LLC

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	207W00000X	Ophthalmology Physician	01058885A	IN
2	261QA1903X	Ambulatory Surgical Clinic/Center	13 012741 1	IN

General Provider Information

NPI Number	:	1730442559
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RETINA INSTITUTE OF INDIANA SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	11192 DIEBOLD RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-9662
Country	:	US
Telephone Number	:	260-483-9500
Fax Number	:	260-483-9511

Provider Business Practice Location Address
First Line	:	11192 DIEBOLD RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-9662
Country	:	US
Telephone Number	:	260-483-9500
Fax Number	:	260-483-9511

Authorized Official
Title or Position	:	SOLE MBR
Name	:	GOHAR AZAM SALAM
Credential	:	MD
Telephone Number	:	260-483-9500

Provider Enumeration Date	:	06/18/2012
Last Update Date	:	03/03/2016

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