Provider Demographics
NPI:1750327268
Name:SANDERS MOBILE PODIATRY INC
Entity Type:Organization
Organization Name:SANDERS MOBILE PODIATRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:410-493-9439
Mailing Address - Street 1:1405 DECATUR ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-5212
Mailing Address - Country:US
Mailing Address - Phone:410-493-9439
Mailing Address - Fax:443-836-0722
Practice Address - Street 1:1405 DECATUR ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-5212
Practice Address - Country:US
Practice Address - Phone:410-493-9439
Practice Address - Fax:443-836-0722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEE10000178213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD01405OtherMARYLAND PODIATRY LIC#
276275Medicare UPIN
MD200PMedicare ID - Type UnspecifiedGROUP MEDICARE NUMBER