Provider Demographics
NPI:1386837581
Name:CHARM CITY PODIATRY, LLC
Entity Type:Organization
Organization Name:CHARM CITY PODIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WOODBURN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:410-828-7200
Mailing Address - Street 1:7505 OSLER DR
Mailing Address - Street 2:SUITE 307
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-7736
Mailing Address - Country:US
Mailing Address - Phone:410-828-7200
Mailing Address - Fax:410-828-7201
Practice Address - Street 1:7505 OSLER DR
Practice Address - Street 2:SUITE 307
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7736
Practice Address - Country:US
Practice Address - Phone:410-828-7200
Practice Address - Fax:410-828-7201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01343213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6092740001Medicare NSC