1760660641 NPI number — FOOT AND ANKLE SPECIALISTS OF THE MID-ATLANTIC LLC

Table of content: (NPI 1760660641)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760660641 NPI number — FOOT AND ANKLE SPECIALISTS OF THE MID-ATLANTIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOT AND ANKLE SPECIALISTS OF THE MID-ATLANTIC 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:
6
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:
1760660641
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
714 CHASE PKWY
Provider Second Line Business Mailing Address:
SUITE 4
Provider Business Mailing Address City Name:
WATERBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06708-3012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-755-0489
Provider Business Mailing Address Fax Number:
203-755-7523

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
714 CHASE PKWY
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
WATERBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06708-3012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-755-0489
Provider Business Practice Location Address Fax Number:
203-755-7523
Provider Enumeration Date:
02/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TRITTO
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
DPM/OWNER
Authorized Official Telephone Number:
301-933-7133

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  548 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: 548 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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