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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