1831192095 NPI number — DEBRA R. BOENDER, DPM, PHD, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831192095 NPI number — DEBRA R. BOENDER, DPM, PHD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEBRA R. BOENDER, DPM, PHD, 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:
1831192095
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26553 MARINERS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRISFIELD
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21817-2109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-465-4410
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26553 MARINERS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRISFIELD
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21817-2109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-465-4410
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BOENDER
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
R
Authorized Official Title or Position:
SOLE PRACTITIONER/PROPRIETOR
Authorized Official Telephone Number:
410-465-4410

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  01409 , 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: 002485895002 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 002216100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01409 . This is a "MARYLAND STATE LICENSE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: DC9138 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 606937400 . This is a "FED WORKERS COMP/DOL" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 689BP0/64490301 . This is a "CAREFIRST BC/BS NASCO" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: K4150001 . This is a "CAREFIRST FED AND DC AREA" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 2137828 . This is a "ONE NET" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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