Healthcare Provider Details

I. General information

NPI: 1457520983
Provider Name (Legal Business Name): LAUREL LAKES FOOT AND ANKLE ASC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2008
Last Update Date: 02/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13950 BALTIMORE AVE
LAUREL MD
20707-5000
US

IV. Provider business mailing address

13950 BALTIMORE AVE
LAUREL MD
20707-5000
US

V. Phone/Fax

Practice location:
  • Phone: 301-317-6800
  • Fax: 301-317-4183
Mailing address:
  • Phone: 301-317-6800
  • Fax: 301-317-4183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number00560
License Number StateMD

VIII. Authorized Official

Name: DR. SCOTT W NUTTER
Title or Position: PRESIDENT
Credential: DPM
Phone: 301-317-6800