Provider Demographics
NPI:1447378328
Name:GREENE TREE FOOT ANKLE SURGICENTER
Entity type:Organization
Organization Name:GREENE TREE FOOT ANKLE SURGICENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:D
Authorized Official - Last Name:BURNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-602-8637
Mailing Address - Street 1:1838 GREENE TREE RD
Mailing Address - Street 2:SUITE 430
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-6391
Mailing Address - Country:US
Mailing Address - Phone:410-602-8637
Mailing Address - Fax:410-602-9781
Practice Address - Street 1:1838 GREENE TREE RD
Practice Address - Street 2:SUITE 430
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21208-6391
Practice Address - Country:US
Practice Address - Phone:410-602-8637
Practice Address - Fax:410-602-9781
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREENE TREE FOOT ANKLE SURGICENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-27
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1419261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD409817000Medicaid
MD192ZMedicare PIN