Provider Demographics
NPI:1770734915
Name:LAUREL LAKES FOOT AND ANKLE CENTER, LLC
Entity type:Organization
Organization Name:LAUREL LAKES FOOT AND ANKLE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM
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:
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
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
VA252513OtherBLUE SHIELD OF VA
91242OtherAETNA
DC0001OtherBLUE SHIELD OF DC
MD41866201OtherBLUE SHIELD OF MD
MD7998686000Medicaid
MD91242OtherMAMSI
998EOtherTRICARE
A050OtherAMERGROUP
496067OtherNCPPO
91242OtherAETNA
998EOtherTRICARE
DC0001OtherBLUE SHIELD OF DC
496067OtherNCPPO