Provider Demographics
NPI:1548458664
Name:THE PODIATRY CARE CENTER, LLC
Entity type:Organization
Organization Name:THE PODIATRY CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:301-352-3668
Mailing Address - Street 1:12150 ANNAPOLIS RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9179
Mailing Address - Country:US
Mailing Address - Phone:301-352-3668
Mailing Address - Fax:301-352-3669
Practice Address - Street 1:12150 ANNAPOLIS RD
Practice Address - Street 2:SUITE 109
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769-9179
Practice Address - Country:US
Practice Address - Phone:301-352-3668
Practice Address - Fax:301-352-3669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01318213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD86546OtherAMERIGROUP
MDJ2590001OtherBLUECROSS AND BLUESHIELD
MD5394560001OtherDMERC PIN
MD7294202OtherAETNA
MDDF6331OtherPALMETTO GBA - RAILROAD MEDICARE
MD134103100Medicaid
MD583402OtherMAMSI/MDIPA/OPT CHOICE
MD62204301OtherBLUECROSS AND BLUESHIELD
MD86546OtherAMERIGROUP
MD583402OtherMAMSI/MDIPA/OPT CHOICE