Retina Institute of Indiana Surgery Center, LLC

Primary specialty

Ambulatory Surgical Clinic/CenterTaxonomy code 261QA1903X

License

13 012741 1 Issued in IN

Legal business name

RETINA INSTITUTE OF INDIANA SURGERY CENTER, LLC

Practice address

11192 Diebold Rd
Fort Wayne, IN 46845-9662

Phone

(260) 483-9500

Fax

(260) 483-9511

NPI assigned

Jun 18, 2012

Last updated

Mar 3, 2016By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Gohar Azam Salam, MDNPI 1285635334

Title

Sole MBR

Phone

(260) 483-9500

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in IN

Enrollment records 1

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1730442559. Details of each certification follow.

• CCN 15C0001187 Ambulatory surgical center · Active · Name & address match · Details

Ambulatory surgical center certification: CCN 15C0001187

Legal name

RETINA INSTITUTE OF INDIANA SURGERY CENTER, LLC

Certification status

Active

Provider type (POS)

Ambulatory surgical center

Participating since

Aug 26, 2013

Last certification

Aug 31, 2016

Ownership / control type

Proprietary

Facility address

11192 Diebold Road
Fort Wayne, IN 46845

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Gohar A Salam, M.D., F.A.C.S.

  • Ophthalmology Physician
  • Fort Wayne, IN
  • NPI 1285635334
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1339977600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1456963200000",
    "number": "1730442559",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11192 DIEBOLD RD",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468459662",
            "telephone_number": "260-483-9500",
            "fax_number": "260-483-9511"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11192 DIEBOLD RD",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468459662",
            "telephone_number": "260-483-9500",
            "fax_number": "260-483-9511"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RETINA INSTITUTE OF INDIANA SURGERY CENTER, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-06-18",
        "last_updated": "2016-03-03",
        "status": "A",
        "authorized_official_last_name": "SALAM",
        "authorized_official_first_name": "GOHAR",
        "authorized_official_middle_name": "AZAM",
        "authorized_official_title_or_position": "SOLE MBR",
        "authorized_official_telephone_number": "260-483-9500",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207W00000X",
            "taxonomy_group": "",
            "desc": "Ophthalmology",
            "state": "IN",
            "license": "01058885A",
            "primary": false
        },
        {
            "code": "261QA1903X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Ambulatory Surgical",
            "state": "IN",
            "license": "13 012741 1",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Responsive Home Health Care Inc (Rotech)
• Paul Arthur Reszel, MD
• Clayton Retherford, DMD
• Lorah Retherford, DPT
• Whitney Rethlake
• Retina Institute of Indiana, P.C.
• Philip A Rettenmaier, DO
• Andrew Reum II
• Hugh Fredrick Reusser, MSW
• Susan Diane Reusser, LCSW

• Ambulatory Surgical Clinic/Center in Fort Wayne, IN
• Providers in Fort Wayne, IN by specialty
• Ambulatory Surgical Clinic/Center in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 3, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.