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General NPI Number Information
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NPI Number | 1386822104
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Entity Type | Organization
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Legal Business Name | MICKENBERGS AMBULATORY FOOT CARE PA
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Dates
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Enumeration Date | 02/04/2008
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Last Update Date | 04/14/2011
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Provider Practice Location Address
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Address Line | 8094 EDWIN RAYNOR BLVD STE C
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City | PASADENA
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State | MD
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Zip | 21122-6834
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Country | US
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Telephone | 410-255-0040
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Fax | 410-360-4955
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Provider Business Mailing Address
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Address Line | 8094 EDWIN RAYNOR BLVD STE C
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City | PASADENA
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State | MD
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Zip | 21122-6834
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Country | US
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Telephone | 410-255-0040
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Fax | 410-360-4955
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Authorized Official
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Title or Position | OWNER
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Name | DR. JAY MARC MICKENBERG
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Credential | DPM
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Telephone | 410-255-0040
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 01053
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License Number State | MD
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Taxonomy #2
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 01053
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License Number State | MD
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