1194155663 NPI number — MARYLAND FOOT & ANKLE RESTORATION, 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 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:
11/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 86284
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTGOMERY VILLAGE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20886-6284
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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