Provider Demographics
NPI:1083955405
Name:CAPITAL FOOT & ANKLE CARE CENTRE PA
Entity Type:Organization
Organization Name:CAPITAL FOOT & ANKLE CARE CENTRE PA
Other - Org Name:PRINCE FREDERICK FOOT & ANKLE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:VANFOSSON
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 1:995 PRINCE FREDERICK BLVD
Practice Address - Street 2:STE. 104
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-3198
Practice Address - Country:US
Practice Address - Phone:410-414-5033
Practice Address - Fax:301-862-3335
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAPITAL FOOT & ANKLE CARE CENTRE PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD231308100Medicaid
MD539LMedicare PIN
MD0256190002Medicare PIN