1386822104 NPI number — MICKENBERGS AMBULATORY FOOT CARE PA

Table of content: (NPI 1386822104)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386822104 NPI number — MICKENBERGS AMBULATORY FOOT CARE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MICKENBERGS AMBULATORY FOOT CARE PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386822104
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8094 EDWIN RAYNOR BLVD
Provider Second Line Business Mailing Address:
STE C
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21122-6834
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-255-0040
Provider Business Mailing Address Fax Number:
410-360-4955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8094 EDWIN RAYNOR BLVD
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21122-6834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-255-0040
Provider Business Practice Location Address Fax Number:
410-360-4955
Provider Enumeration Date:
02/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MICKENBERG
Authorized Official First Name:
JAY
Authorized Official Middle Name:
MARC
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
410-255-0040

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  01053 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: 01053 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1338463 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1386822104 . This is a "COVENTRY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1386822104 . This is a "MAMSI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1386822104 . This is a "ALLIANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: T276 . This is a "CAREFIRST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 1386822104 . This is a "FIRST HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1386822104 . This is a "FIDELITY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1386822104 . This is a "EHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 217484 . This is a "MDIPA/OPTIMUM CHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 062308307 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1386822104 . This is a "EMPLOYER HEALTH INSURANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 480012800 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: B765 001 . This is a "CAREFIRST FEDERAL EMPLOYEE PROGRAM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1386822104 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1386822104 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: T765 . This is a "BLUE CHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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