# RETINA INSTITUTE OF INDIANA SURGERY CENTER, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1730442559
- **Authorized official:** GOHAR AZAM SALAM MD (SOLE MBR)
- **Authorized official phone:** (260) 483-9500

## Contact information

- **Practice address:** 11192 DIEBOLD RD, FORT WAYNE, IN 46845-9662
- **Practice address phone:** (260) 483-9500
- **Practice address fax:** (260) 483-9511
- **Mailing address:** 11192 DIEBOLD RD, FORT WAYNE, IN 46845-9662
- **Mailing address phone:** (260) 483-9500
- **Mailing address fax:** (260) 483-9511

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207W00000X | Ophthalmology Physician | 01058885A | IN | — |
| 261QA1903X | Ambulatory Surgical Clinic/Center | 13 012741 1 | IN | Yes |

## Other

- **Enumeration date:** 06/18/2012
- **Last updated:** 03/03/2016