Provider Demographics
NPI:1043495641
Name:FOOT AND ANKLE CENTER OF FORT LEE, LLC
Entity type:Organization
Organization Name:FOOT AND ANKLE CENTER OF FORT LEE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GAVRIIL
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAIMOV
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:201-363-9844
Mailing Address - Street 1:2225 LEMOINE AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-6104
Mailing Address - Country:US
Mailing Address - Phone:201-363-9844
Mailing Address - Fax:201-363-9662
Practice Address - Street 1:2225 LEMOINE AVE FL 1
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-6104
Practice Address - Country:US
Practice Address - Phone:201-363-9844
Practice Address - Fax:201-363-9662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00295000213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ123276X43Medicare PIN
NJ6081380001Medicare NSC
NJ123278Medicare PIN