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General NPI Number Information
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NPI Number | 1518083443
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Entity Type | Organization
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Legal Business Name | SHADY GROVE PODIATRY, LLC
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Dates
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Enumeration Date | 03/22/2007
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Last Update Date | 09/13/2011
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Provider Practice Location Address
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Address Line | 16220 S FREDERICK AVE SUITE 427
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City | GAITHERSBURG
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State | MD
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Zip | 20877-4039
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Country | US
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Telephone | 301-948-2995
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Fax | 301-948-6056
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Provider Business Mailing Address
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Address Line | 16220 S FREDERICK AVE SUITE 427
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City | GAITHERSBURG
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State | MD
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Zip | 20877-4039
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Country | US
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Telephone | 301-948-2995
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Fax | 301-948-6056
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Authorized Official
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Title or Position | MANAGING PARTNER
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Name | DR. RONALD ALLEN FOOTER
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Credential | D.P.M.
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Telephone | 301-948-2995
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 00360
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License Number State | MD
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