Provider Demographics
NPI:1568498301
Name:FOOT AND ANKLE CARE OF FREDERICK, INC
Entity Type:Organization
Organization Name:FOOT AND ANKLE CARE OF FREDERICK, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:GRACE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:301-698-9260
Mailing Address - Street 1:604 SOLAREX CT
Mailing Address - Street 2:UNIT 103
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-8678
Mailing Address - Country:US
Mailing Address - Phone:301-698-9260
Mailing Address - Fax:301-698-8962
Practice Address - Street 1:604 SOLAREX CT
Practice Address - Street 2:UNIT 103
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-8678
Practice Address - Country:US
Practice Address - Phone:301-698-9260
Practice Address - Fax:301-698-8962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01249213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD403808801Medicaid
MD1457320814OtherINDIVIDUAL NPI
MDDD4719OtherMEDICARE RAILROAD
MD019538300OtherDME - MEDICAID
MD403808800Medicaid
MD717MMedicare ID - Type UnspecifiedGROUP NUMBER
MD403808800Medicaid