Provider Demographics
NPI:1386822104
Name:MICKENBERGS AMBULATORY FOOT CARE PA
Entity Type:Organization
Organization Name:MICKENBERGS AMBULATORY FOOT CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:MARC
Authorized Official - Last Name:MICKENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:410-255-0040
Mailing Address - Street 1:8094 EDWIN RAYNOR BLVD
Mailing Address - Street 2:STE C
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-6834
Mailing Address - Country:US
Mailing Address - Phone:410-255-0040
Mailing Address - Fax:410-360-4955
Practice Address - Street 1:8094 EDWIN RAYNOR BLVD
Practice Address - Street 2:STE C
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-6834
Practice Address - Country:US
Practice Address - Phone:410-255-0040
Practice Address - Fax:410-360-4955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01053213E00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1338463OtherCIGNA
1386822104OtherCOVENTRY
1386822104OtherMAMSI
1386822104OtherALLIANCE
MDT276OtherCAREFIRST
1386822104OtherFIRST HEALTH
1386822104OtherFIDELITY
1386822104OtherEHP
217484OtherMDIPA/OPTIMUM CHOICE
MD062308307Medicaid
1386822104OtherEMPLOYER HEALTH INSURANCE
480012800OtherRAILROAD MEDICARE
B765 001OtherCAREFIRST FEDERAL EMPLOYEE PROGRAM
1386822104OtherTRICARE
1386822104OtherUNITED HEALTHCARE
MDT765OtherBLUE CHOICE
1386822104OtherEHP
480012800OtherRAILROAD MEDICARE
T93190Medicare UPIN