Provider Demographics
NPI:1891170619
Name:EASTERN SHORE FAMILY FOOT CARE, LLC
Entity Type:Organization
Organization Name:EASTERN SHORE FAMILY FOOT CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLI
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-758-5446
Mailing Address - Street 1:970 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHESTERTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21620-3322
Mailing Address - Country:US
Mailing Address - Phone:410-778-1801
Mailing Address - Fax:410-758-3249
Practice Address - Street 1:510 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:MD
Practice Address - Zip Code:21629-1368
Practice Address - Country:US
Practice Address - Phone:410-819-0096
Practice Address - Fax:410-479-4622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-22
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
264MMedicare PIN