Provider Demographics
NPI:1053320580
Name:CAPITAL FOOT & ANKLE CARE CENTRE PA
Entity Type:Organization
Organization Name:CAPITAL FOOT & ANKLE CARE CENTRE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:H
Authorized Official - Last Name:HALLGREN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:301-862-3338
Mailing Address - Street 1:PO BOX 1310
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA
Mailing Address - State:MD
Mailing Address - Zip Code:20619-1310
Mailing Address - Country:US
Mailing Address - Phone:301-862-3338
Mailing Address - Fax:301-862-3335
Practice Address - Street 1:22325 GREENVIEW PKWY
Practice Address - Street 2:
Practice Address - City:GREAT MILLS
Practice Address - State:MD
Practice Address - Zip Code:20634-3491
Practice Address - Country:US
Practice Address - Phone:301-862-3338
Practice Address - Fax:301-862-3335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A213ES0103X
MD01346332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKS57OtherBC/BS OF MD
MD231309100Medicaid
MDKS57OtherBC/BS OF MD
MD231309100Medicaid