1548458664 NPI number — THE PODIATRY CARE CENTER, LLC

Table of content: (NPI 1548458664)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548458664 NPI number — THE PODIATRY CARE CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE PODIATRY CARE CENTER, LLC
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:
1548458664
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12150 ANNAPOLIS RD
Provider Second Line Business Mailing Address:
SUITE 109
Provider Business Mailing Address City Name:
GLENN DALE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20769-9179
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-352-3668
Provider Business Mailing Address Fax Number:
301-352-3669

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12150 ANNAPOLIS RD
Provider Second Line Business Practice Location Address:
SUITE 109
Provider Business Practice Location Address City Name:
GLENN DALE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20769-9179
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-352-3668
Provider Business Practice Location Address Fax Number:
301-352-3669
Provider Enumeration Date:
10/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NELSON
Authorized Official First Name:
RHONDA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
301-352-3668

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  01318 , 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: 86546 . This is a "AMERIGROUP" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: J2590001 . This is a "BLUECROSS AND BLUESHIELD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 5394560001 . This is a "DMERC PIN" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 7294202 . This is a "AETNA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: DF6331 . This is a "PALMETTO GBA - RAILROAD MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 134103100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 583402 . This is a "MAMSI/MDIPA/OPT CHOICE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 62204301 . This is a "BLUECROSS AND BLUESHIELD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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