1659377166 NPI number — FOOT SURGI-CENTER OF OWINGS MILLS, LLC

Table of content: (NPI 1659377166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659377166 NPI number — FOOT SURGI-CENTER OF OWINGS MILLS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOT SURGI-CENTER OF OWINGS MILLS, 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:
1659377166
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 CROSSROADS DR
Provider Second Line Business Mailing Address:
STE 410
Provider Business Mailing Address City Name:
OWINGS MILLS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21117-5439
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-363-2233
Provider Business Mailing Address Fax Number:
410-363-2235

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 CROSSROADS DR
Provider Second Line Business Practice Location Address:
STE 410
Provider Business Practice Location Address City Name:
OWINGS MILLS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21117-5439
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-363-2233
Provider Business Practice Location Address Fax Number:
410-363-2235
Provider Enumeration Date:
06/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
DIAMOND
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
410-363-2233

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  A1397 , 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: 3768322 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 406146200 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: P10037 . This is a "INFORMED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 64190001 . This is a "BCBS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 689786 . This is a "NCPPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 109235 . This is a "EMPLOYERS HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: RPI . This is a "BCBS" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".
  • Identifier: 7973633 . This is a "AETNA PPO" identifier . This identifiers is of the category "OTHER".




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