NPIMap

Organization Active NPI

Mickenbergs Ambulatory Foot Care PA

  • Durable Medical Equipment & Medical Supplies
  • Pasadena, MD
National Provider Identifier
1386822104
Registry record updated Apr 14, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Durable Medical Equipment & Medical SuppliesTaxonomy code 332B00000X
License
01053 Issued in MD
Legal business name
MICKENBERGS AMBULATORY FOOT CARE PA
Practice address
8094 Edwin Raynor Blvd
Ste C
Pasadena, MD 21122-6834
Phone
(410) 255-0040
Fax
(410) 360-4955
NPI assigned
Feb 4, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 14, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Jay Marc Mickenberg, DPMNPI 1336149962
Title
Owner
Phone
(410) 255-0040

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
PodiatristGroup: 193400000X SINGLE SPECIALTY GROUP 213E00000X 01053 MD
Durable Medical Equipment & Medical Supplies 332B00000X 01053 MD Primary

Addresses

Primary practice location

8094 Edwin Raynor Blvd
Ste C
Pasadena, MD 21122-6834

Mailing address

8094 Edwin Raynor Blvd
Ste C
Pasadena, MD 21122-6834
Phone (410) 255-0040

Other identifiers 16

IdentifierTypeStateIssuer
1338463OtherCIGNA
1386822104OtherCOVENTRY
1386822104OtherMAMSI
1386822104OtherALLIANCE
T276OtherMDCAREFIRST
1386822104OtherFIRST HEALTH
1386822104OtherFIDELITY
1386822104OtherEHP
217484OtherMDIPA/OPTIMUM CHOICE
062308307MedicaidMD
1386822104OtherEMPLOYER HEALTH INSURANCE
480012800OtherRAILROAD MEDICARE
B765 001OtherCAREFIRST FEDERAL EMPLOYEE PROGRAM
1386822104OtherTRICARE
1386822104OtherUNITED HEALTHCARE
T765OtherMDBLUE CHOICE

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MD2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20100930065407 MD DME Supplier - Physician - Podiatry 6608995725 Practice locations: Pasadena, MD
O20110510000850 MD Part B Supplier - Clinic/Group Practice 6608995725 Receives reassigned benefits from 1 practitioner
Practice locations: Pasadena, MD

National Provider Directory

National Provider Directory

Locations

8094 Edwin Raynor Blvd
Pasadena, MD 21122

8094 Edwin Raynor Blvd
Ste C
Pasadena, MD 21122
Phone (410) 255-0040

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1202083200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1302739200000",
    "number": "1386822104",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8094 EDWIN RAYNOR BLVD",
            "address_2": "STE C",
            "city": "PASADENA",
            "state": "MD",
            "postal_code": "211226834",
            "telephone_number": "410-255-0040",
            "fax_number": "410-360-4955"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8094 EDWIN RAYNOR BLVD",
            "address_2": "STE C",
            "city": "PASADENA",
            "state": "MD",
            "postal_code": "211226834",
            "telephone_number": "410-255-0040",
            "fax_number": "410-360-4955"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MICKENBERGS AMBULATORY FOOT CARE PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-02-04",
        "last_updated": "2011-04-14",
        "status": "A",
        "authorized_official_last_name": "MICKENBERG",
        "authorized_official_first_name": "JAY",
        "authorized_official_middle_name": "MARC",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "410-255-0040",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DPM"
    },
    "taxonomies": [
        {
            "code": "213E00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Podiatrist",
            "state": "MD",
            "license": "01053",
            "primary": false
        },
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": "MD",
            "license": "01053",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CIGNA",
            "identifier": "1338463",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "COVENTRY",
            "identifier": "1386822104",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MAMSI",
            "identifier": "1386822104",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ALLIANCE",
            "identifier": "1386822104",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CAREFIRST",
            "identifier": "T276",
            "state": "MD"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "FIRST HEALTH",
            "identifier": "1386822104",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "FIDELITY",
            "identifier": "1386822104",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "EHP",
            "identifier": "1386822104",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MDIPA/OPTIMUM CHOICE",
            "identifier": "217484",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "062308307",
            "state": "MD"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "EMPLOYER HEALTH INSURANCE",
            "identifier": "1386822104",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "480012800",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CAREFIRST FEDERAL EMPLOYEE PROGRAM",
            "identifier": "B765 001",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "TRICARE",
            "identifier": "1386822104",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UNITED HEALTHCARE",
            "identifier": "1386822104",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CHOICE",
            "identifier": "T765",
            "state": "MD"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Pasadena, MD

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 14, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.