| Organization Name: | FOOT AND ANKLE CENTER OF FORT LEE, LLC |
| NPI Number: | 1043495641 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | GAVRIIL KHAIMOV (PRESIDENT) |
| Mailing Address: | 185 Bridge Plz N Suite #4 Fort Lee |
| State: | NJ US |
| Postal Code: | 070245907 |
| Phone Number: | 2013639844 |
| Fax Number: | 2013639662 |
| NPI Enumeration Date: | 01/02/2008 |
| NPI Last Update Date: | 10/01/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 213ES0103X |
| License Number: | 25MD00295000 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NJ |
| Taxonomy Type: | Podiatric Medicine & Surgery Service Providers |
| Taxonomy Classification: | Podiatrist |
| Taxonomy Specialization: | Foot & Ankle Surgery |
| Taxonomy Definition: | |