Provider Demographics
NPI:1518135441
Name:CCRAB ASSOCIATES, LLC
Entity Type:Organization
Organization Name:CCRAB ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WENZEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-645-0366
Mailing Address - Street 1:3261 OLD WASHINGTON RD
Mailing Address - Street 2:SUITE 1010
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-3223
Mailing Address - Country:US
Mailing Address - Phone:301-645-0366
Mailing Address - Fax:301-843-4773
Practice Address - Street 1:3261 OLD WASHINGTON RD
Practice Address - Street 2:SUITE 1010
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3223
Practice Address - Country:US
Practice Address - Phone:301-645-0366
Practice Address - Fax:301-843-4773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00399213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD403912200Medicaid
MDT73273Medicare UPIN
MD6040730001Medicare NSC
MD599PMedicare PIN