Organization
MICKENBERGS AMBULATORY FOOT CARE PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JAY MARC MICKENBERG DPM (OWNER)
(410) 255-0040
Entity
Organization
Contact information
Practice address
8094 EDWIN RAYNOR BLVD, STE C, PASADENA, MD 21122-6834
(410) 255-0040
(410) 360-4955
Mailing address
8094 EDWIN RAYNOR BLVD, STE C, PASADENA, MD 21122-6834
(410) 255-0040
(410) 360-4955
Taxonomy
Speciality
Code
Description
License number
State
213E00000X
Podiatrist
01053
MD
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
01053
MD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
062308307
—
MD
01
—
1338463
CIGNA
—
01
—
1386822104
COVENTRY
—
01
—
217484
MDIPA/OPTIMUM CHOICE
—
01
—
480012800
RAILROAD MEDICARE
—
01
—
B765 001
CAREFIRST FEDERAL EMPLOYEE PROGRAM
—
01
—
T276
CAREFIRST
MD
01
—
T765
BLUE CHOICE
MD
Enumeration date
02/04/2008
Last updated
04/14/2011
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