Healthcare Provider Details

I. General information

NPI: 1427234327
Provider Name (Legal Business Name): FOOT AND ANKLE CENTER OF SOUTHERN MAINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2008
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 PORTLAND RD
KENNEBUNK ME
04043-6602
US

IV. Provider business mailing address

75 PORTLAND RD
KENNEBUNK ME
04043-6602
US

V. Phone/Fax

Practice location:
  • Phone: 207-985-9888
  • Fax: 207-985-3488
Mailing address:
  • Phone: 207-985-9888
  • Fax: 207-985-3488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier133240000
Identifier TypeMEDICAID
Identifier StateME
Identifier Issuer

VIII. Authorized Official

Name: DR. DAVID J MICCA
Title or Position: OWNER
Credential: DPM
Phone: 207-985-9888