MEDICARE: FOOTPRINT PODIATRY CONSULTANTS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP1100X	Podiatric Clinic/Center	PO1000031	DC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	306106	OTHER	DC	UNISON
2	947AMD-MD	OTHER	DC	CAREFIRST BC/BS
3	0000289842002	OTHER	DC	UNITED HEALTHCARE
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	J892	OTHER	DC	CAREFIRST BC/BS
6	31290	OTHER	DC	DC CHARTERED HEALTH

General Provider Information

NPI Number	:	1083932438
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOOTPRINT PODIATRY CONSULTANTS, LLC

Provider Business Mailing Address
First Line	:	4316 18TH ST NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20011-4228
Country	:	US
Telephone Number	:	202-412-9664
Fax Number	:	202-525-2348

Provider Business Practice Location Address
First Line	:	1328 SOUTHERN AVE SE
Second Line	:	SUITE 209
City	:	WASHINGTON
State	:	DC
Zip	:	20032-4689
Country	:	US
Telephone Number	:	202-506-1001
Fax Number	:	202-506-1008

Authorized Official
Title or Position	:	PODIATRIST/CEO
Name	:	DR. MICHANGELO DARREN SCRUGGS
Credential	:	DPM
Telephone Number	:	202-506-1001

Provider Enumeration Date	:	05/10/2010
Last Update Date	:	08/02/2010

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