Basic Information
| Provider Information | |||||||||
| NPI: | 1568498301 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOOT AND ANKLE CARE OF FREDERICK, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 604 SOLAREX CT | ||||||||
| Address2: | UNIT 103 | ||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217038678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016989260 | ||||||||
| FaxNumber: | 3016988962 | ||||||||
| Practice Location | |||||||||
| Address1: | 604 SOLAREX CT | ||||||||
| Address2: | UNIT 103 | ||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217038678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016989260 | ||||||||
| FaxNumber: | 3016988962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 11/11/2009 | ||||||||
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| AuthorizedOfficialLastName: | GRACE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | MARK | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3016989260 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 01249 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 403808801 | 05 | MD | MEDICAID | 1457320814 | 01 | MD | INDIVIDUAL NPI | OTHER | DD4719 | 01 | MD | MEDICARE RAILROAD | OTHER | 019538300 | 01 | MD | DME - MEDICAID | OTHER | 403808800 | 05 | MD | MEDICAID |