Healthcare Provider Details

I. General information

NPI: 1104865005
Provider Name (Legal Business Name): FOOT AND ANKLE SPECIALISTS OF THE MID-ATLANTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 DIXON ST STE 201
FREDERICKSBURG VA
22401-7231
US

IV. Provider business mailing address

PO BOX 825159
PHILADELPHIA PA
19182-5159
US

V. Phone/Fax

Practice location:
  • Phone: 540-374-5261
  • Fax: 540-374-5262
Mailing address:
  • Phone: 301-933-7133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0103300938
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL TRITTO
Title or Position: OWNER
Credential:
Phone: 301-933-7133