1194155663 NPI number — MARYLAND FOOT & ANKLE RESTORATION, LLC

Table of content: (NPI 1194155663)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194155663 NPI number — MARYLAND FOOT & ANKLE RESTORATION, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARYLAND FOOT & ANKLE RESTORATION, 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:
1194155663
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 83849
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAITHERSBURG
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20883-3849
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-699-5900
Provider Business Mailing Address Fax Number:
301-699-9297

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6505 BELCREST RD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
HYATTSVILLE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20782-2011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-699-5900
Provider Business Practice Location Address Fax Number:
301-699-9297
Provider Enumeration Date:
11/20/2013

Additional Information

Authorized Official

Authorized Official Last Name:
MOTRAN
Authorized Official First Name:
JOHNY
Authorized Official Middle Name:
JAMAL
Authorized Official Title or Position:
PODIATRIST/LEADING MEMBER
Authorized Official Telephone Number:
301-699-5900

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  01450 , 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: 415792300 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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