Form 4 DEA/Federal Licensure

the

DataBank

DCN: 5950000090960782
Process Date: 12/08/2014
Page: 1
of
3
MANN, ANITTA
For authorized use by:
MERGE13 STAT16 TESTING

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb.hrsa.gov

MANN, ANITTA
MERGE13 STAT16 TESTING
DEA/FEDERAL LICENSURE ACTION

Date of Action: 11/15/2014

Initial Action
- REVOCATION OF LICENSE
- SUSPENSION OF LICENSE

A. REPORTING
ENTITY

Entity Name:
Address:
City, State, Zip:
Country:
Name or Office:
Title or Department:
Telephone:
Entity Internal Report Reference:
Type of Report:

Subject Name:
Other Name(s) Used:
Gender:
Date of Birth:
Organization Name:
Work Address:
City, State, ZIP:
Organization Type:
Home Address:
City, State, ZIP:
Deceased:
Federal Employer Identification Numbers (FEIN):
Social Security Numbers (SSN):
Individual Taxpayer Identification Numbers (ITIN):
National Provider Identifiers (NPI):
Professional School(s) & Year(s) of Graduation:
Occupation/Field of Licensure (Code):
State License Number, State of Licensure:
Drug Enforcement Administration (DEA) Numbers:
Unique Physician Identification Numbers (UPIN):
Name(s) of Health Care Entity (Entities) With Which Subject Is
Affiliated or Associated (Inclusion Does Not Imply Complicity in
the Reported Action.):
Business Address of Affiliate:
City, State, ZIP:
Nature of Relationship(s):

B. SUBJECT
IDENTIFICATION
INFORMATION
(INDIVIDUAL)

Basis for Initial Action
- LICENSE REVOCATION, SUSPENSION OR OTHER
DISCIPLINARY ACTION TAKEN BY A FEDERAL, STATE OR
LOCAL LICENSING AUTHORITY
MERGE13 STAT16 TESTING
109 GERNANY WAY
BANBURG, VA 20175
MERGE13 STATRULE16 TESTING
DEPT
(703) 803-1500
INITIAL
MANN, ANITTA
FEMALE
01/01/1982
LICENSING BOARD
1234 FEDERAL LN
ANNAPOLIS, MD 21401
FEDERAL HOSPITAL (304)
5600 FISHERS LN
ROCKVILLE, MD 20852-1750
NO
***-**-1111

NEW YORK COLLEGE OF PODIATRIC MEDICINE (2006)
PODIATRIST
SL56, MD
AM123456789

FOOTCAREINC

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY

the

DataBank

DCN: 5950000090960782
Process Date: 12/08/2014
Page: 2
of
3
MANN, ANITTA
For authorized use by:
MERGE13 STAT16 TESTING

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb.hrsa.gov

Type of Adverse Action: DEA/FEDERAL LICENSURE
Basis for Action: LICENSE REVOCATION, SUSPENSION OR OTHER DISCIPLINARY
ACTION TAKEN BY A FEDERAL, STATE OR LOCAL LICENSING
AUTHORITY (39)
Name of Agency or Program
That Took the Adverse Action
Specified in This Report: ABC INTEGRITY PROGRAM
Adverse Action
Classification Code(s): REVOCATION OF LICENSE (1110)
SUSPENSION OF LICENSE (1135)
Date Action Was Taken: 11/15/2014
Date Action Became Effective: 11/15/2014
Length of Action: SPECIFIC PERIOD
Years: 2
Months:
Days:
Total Amount of Monetary Penalty,
Assessment and/or Restitution: $ 1,000.00
Is Subject Automatically Reinstated After
Adverse Action Period Is Completed?: YES, WITH CONDITIONS (REQUIRES A REVISION TO ACTION
REPORT WHEN STATUS CHANGES)
Description of Subject's Act(s) or Omission(s) or Other
Reasons for Action(s) Taken and Description of Action(s) Taken
by Reporting Entity: FEDERAL LICENSURE ACTION RELATED TO DRUG ENFORCEMENT
ADMINISTRATION REGISTRATION.

C. INFORMATION
REPORTED

X

Subject identified in Section B has appealed the reported adverse action.
Date of Appeal: 12/22/2014

D. SUBJECT
STATEMENT

If the subject identified in Section B of this report has submitted a statement, it appears in this section.

E. REPORT STATUS

Unless a box below is checked, the subject of this report identified in Section B has not contested this report.
This report has been disputed by the subject identified in Section B.
At the request of the subject identified in Section B, this report is being reviewed by the Secretary of the
U.S. Department of Health and Human Services to determine its accuracy and/or whether it complies with
reporting requirements. No decision has been reached.
At the request of the subject identified in Section B, this report was reviewed by the Secretary of the U.S.
Department of Health and Human Services and a decision was reached. The subject has requested that
the Secretary reconsider the original decision.
At the request of the subject identified in Section B, this report was reviewed by
the Secretary of the U.S. Department of Health and Human Services. The Secretary’s decision
is shown below:
Date of Original Submission:

12/08/2014

Date of Most Recent Change:

12/08/2014

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY

the

DataBank

DCN: 5950000090960782
Process Date: 12/08/2014
Page: 3
of
3
MANN, ANITTA
For authorized use by:
MERGE13 STAT16 TESTING

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb.hrsa.gov

This report is maintained under the provisions of: Section 1128E
The information contained in this report is maintained by the National Practitioner Data Bank for restricted use under the
provisions of Section 1128E of the Social Security Act, and 45 CFR Part 60. All information is confidential and may be used only
for the purpose for which it was disclosed. Disclosure or use of confidential information for other purposes is a violation of federal
law. For additional information or clarification, contact the reporting entity identified in Section A.
END OF REPORT

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY

the

DataBank

DCN: 5950000090960783
Process Date: 12/08/2014
Page: 1
of
2
FOOTCAREINC.
For authorized use by:
MERGE13 STAT16 TESTING

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb.hrsa.gov

FOOTCAREINC.
MERGE13 STAT16 TESTING
DEA/FEDERAL LICENSURE ACTION

Date of Action: 11/11/2014

Initial Action
- REVOCATION OF LICENSE OR CERTIFICATE
- SUSPENSION OF LICENSE OR CERTIFICATE
A. REPORTING
ENTITY

Entity Name:
Address:
City, State, Zip:
Country:
Name or Office:
Title or Department:
Telephone:
Entity Internal Report Reference:
Type of Report:

Organization Name:
Other Organization Name(s) Used:
Business Address:
City, State, ZIP:
Organization Type:
Names and Titles of Principal Officers and Owners (POO):
Federal Employer Identification Numbers (FEIN):
Social Security Numbers (SSN):
Individual Taxpayer Identification Numbers (ITIN):
State License Number, State of Licensure:
Drug Enforcement Administration (DEA) Numbers:
Clinical Laboratory Act (CLIA) Numbers:
Food and Drug Administration (FDA) Numbers:
National Provider Identifiers (NPI):
Medicare Provider/Supplier Numbers:
Name(s) of Health Care Entity (Entities) With Which Subject Is
Affiliated or Associated (Inclusion Does Not Imply Complicity in
the Reported Action.):
Business Address of Affiliate:
City, State, ZIP:
Nature of Relationship(s):

B. SUBJECT
IDENTIFICATION
INFORMATION
(ORGANIZATION)

C. INFORMATION
REPORTED

Basis for Initial Action
- EXCLUSION OR SUSPENSION FROM A FEDERAL OR
STATE HEALTH CARE PROGRAM
MERGE13 STAT16 TESTING
109 GERNANY WAY
BANBURG, VA 20175
MERGE13 STATRULE16 TESTING
DEPT
(703) 803-1500
INITIAL
FOOTCAREINC.
5600 FISHERS LN
ROCKVILLE, MD 20852-1750
PODIATRIC GROUP/PRACTICE (364)
MANN, ANITTA
111111111

SL89, MD

FOOTCAREINC2

Type of Adverse Action: DEA/FEDERAL LICENSURE
Basis for Action: EXCLUSION OR SUSPENSION FROM A FEDERAL OR STATE HEALTH
CARE PROGRAM (40)
Name of Agency or Program
That Took the Adverse Action
Specified in This Report: ABC PROGRAM INTEGRITY
Adverse Action
Classification Code(s): REVOCATION OF LICENSE OR CERTIFICATE (3111)
SUSPENSION OF LICENSE OR CERTIFICATE (3136)
Date Action Was Taken: 11/11/2014

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY

the

DataBank

DCN: 5950000090960783
Process Date: 12/08/2014
Page: 2
of
2
FOOTCAREINC.
For authorized use by:
MERGE13 STAT16 TESTING

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb.hrsa.gov
Date Action Became Effective:
Length of Action:
Years:
Months:
Days:
Total Amount of Monetary Penalty,
Assessment and/or Restitution:
Is Subject Automatically Reinstated After
Adverse Action Period Is Completed?:

11/11/2014
SPECIFIC PERIOD
2
6

$ 5,000.00
YES, WITH CONDITIONS (REQUIRES A REVISION TO ACTION
REPORT WHEN STATUS CHANGES)

Description of Subject's Act(s) or Omission(s) or Other
Reasons for Action(s) Taken and Description of Action(s) Taken
by Reporting Entity: FEDERAL LICENSURE ACTION RELATED TO DRUG ENFORCEMENT
ADMINISTRATION REGISTRATION.
X

Subject identified in Section B has appealed the reported adverse action.
Date of Appeal: 12/12/2014

D. SUBJECT
STATEMENT

If the subject identified in Section B of this report has submitted a statement, it appears in this section.

E. REPORT STATUS

Unless a box below is checked, the subject of this report identified in Section B has not contested this report.
This report has been disputed by the subject identified in Section B.
At the request of the subject identified in Section B, this report is being reviewed by the Secretary of the
U.S. Department of Health and Human Services to determine its accuracy and/or whether it complies with
reporting requirements. No decision has been reached.
At the request of the subject identified in Section B, this report was reviewed by the Secretary of the U.S.
Department of Health and Human Services and a decision was reached. The subject has requested that
the Secretary reconsider the original decision.
At the request of the subject identified in Section B, this report was reviewed by
the Secretary of the U.S. Department of Health and Human Services. The Secretary’s decision
is shown below:
Date of Original Submission:

12/08/2014

Date of Most Recent Change:

12/08/2014

This report is maintained under the provisions of: Section 1128E
The information contained in this report is maintained by the National Practitioner Data Bank for restricted use under the
provisions of Section 1128E of the Social Security Act, and 45 CFR Part 60. All information is confidential and may be used only
for the purpose for which it was disclosed. Disclosure or use of confidential information for other purposes is a violation of federal
law. For additional information or clarification, contact the reporting entity identified in Section A.
END OF REPORT

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY