Basic Information
| Provider Information | |||||||||
| NPI: | 1982881264 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIRKIN FOOT ASSOCIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2415 MUSGROVE RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209045200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019492000 | ||||||||
| FaxNumber: | 3019492002 | ||||||||
| Practice Location | |||||||||
| Address1: | 2415 MUSGROVE RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209045200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013846500 | ||||||||
| FaxNumber: | 3013846670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2008 | ||||||||
| LastUpdateDate: | 11/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | MIRKIN | ||||||||
| AuthorizedOfficialFirstName: | GENE | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3019492000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 061368101 | 05 | MD | MEDICAID |