Basic Information
Provider Information | |||||||||
NPI: | 1356979454 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FOOT AND ANKLE SPECIALISTS OF THE MID-ATLANTIC, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1600 E GUDE DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | ROCKVILLE | ||||||||
State: | MD | ||||||||
PostalCode: | 208501496 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3019337133 | ||||||||
FaxNumber: | 3019337137 | ||||||||
Practice Location | |||||||||
Address1: | 8310 MEDICAL PLAZA DR STE E | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282626703 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7045480222 | ||||||||
FaxNumber: | 7045481157 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/01/2020 | ||||||||
LastUpdateDate: | 04/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TRITTO | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
AuthorizedOfficialTelephone: | 3019337133 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.