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Organization
RETINA INSTITUTE OF INDIANA SURGERY CENTER, LLC
Active
Organization
RETINA INSTITUTE OF INDIANA SURGERY CENTER, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GOHAR AZAM SALAM MD (SOLE MBR)
(260) 483-9500
Entity
Organization
Contact information
Practice address
11192 DIEBOLD RD, FORT WAYNE, IN 46845-9662
(260) 483-9500
(260) 483-9511
Mailing address
11192 DIEBOLD RD, FORT WAYNE, IN 46845-9662
(260) 483-9500
(260) 483-9511
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
01058885A
IN
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
13 012741 1
IN
Other
Enumeration date
06/18/2012
Last updated
03/03/2016
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