Provider Demographics
NPI:1457520983
Name:LAUREL LAKES FOOT AND ANKLE ASC
Entity Type:Organization
Organization Name:LAUREL LAKES FOOT AND ANKLE ASC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:W
Authorized Official - Last Name:NUTTER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:301-317-6800
Mailing Address - Street 1:13950 BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-5000
Mailing Address - Country:US
Mailing Address - Phone:301-317-6800
Mailing Address - Fax:301-317-4183
Practice Address - Street 1:13950 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-5000
Practice Address - Country:US
Practice Address - Phone:301-317-6800
Practice Address - Fax:301-317-4183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD00560261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
91242OtherAETNA
A050OtherAMERIGROUP
496067OtherNCPPO
MD7998686000Medicaid
DC0001OtherBLUE SHIELD OF DC
998EOtherTRICARE
VA252513OtherBLUE SHIELD OF VA
MD91242OtherMAMSI
MD41866201OtherBLUE SHIELD OF MD
DC0001OtherBLUE SHIELD OF DC
MD41866201OtherBLUE SHIELD OF MD
VA252513OtherBLUE SHIELD OF VA
DC000A30507Medicare PIN