Provider Demographics
NPI:1427234327
Name:FOOT AND ANKLE CENTER OF SOUTHERN MAINE
Entity type:Organization
Organization Name:FOOT AND ANKLE CENTER OF SOUTHERN MAINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:MICCA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:207-985-9888
Mailing Address - Street 1:75 PORTLAND RD
Mailing Address - Street 2:
Mailing Address - City:KENNEBUNK
Mailing Address - State:ME
Mailing Address - Zip Code:04043-6602
Mailing Address - Country:US
Mailing Address - Phone:207-985-9888
Mailing Address - Fax:207-985-3488
Practice Address - Street 1:75 PORTLAND RD
Practice Address - Street 2:
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043-6602
Practice Address - Country:US
Practice Address - Phone:207-985-9888
Practice Address - Fax:207-985-3488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME133240000Medicaid
ME133240000Medicaid
MECJ6267Medicare PIN
ME0005296Medicare PIN