Form 14 Exclusion/Debarment

the

DataBank

DCN: 5950000090960775
Process Date: 12/05/2014
Page: 1
of
3
MANN, ANITTA
For authorized use by:
LICENSING BOARD

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

MANN, ANITTA
LICENSING BOARD
EXCLUSION/DEBARMENT ACTION

Date of Action: 10/10/2014

Initial Action
- EXCLUSION FROM A FEDERAL HEALTH CARE
PROGRAM
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
- CONVICTION RELATING TO CONTROLLED SUBSTANCES

LICENSING BOARD
123 CEDAR LANE
ROCKVILLE, MD 20857-0001
JANET DOE
BOARD OFFICIAL
(555) 555-5555
INITIAL
MANN, ANITTA
FEMALE
01/01/1982
GENERAL HOSPITAL
123 CEDAR LANE
ROCKVILLE, MD 20857-0001
GENERAL/ACUTE CARE HOSPITAL (301)
5600 FISHERS LN
ROCKVILLE, MD 20852-1750
NO
***-**-1111

PODIATRIST
SL56, MD
AM111111111

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY

the

DataBank

DCN: 5950000090960775
Process Date: 12/05/2014
Page: 2
of
3
MANN, ANITTA
For authorized use by:
LICENSING BOARD

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

C. INFORMATION
REPORTED

Type of Adverse Action:
Basis for Action:
Name of Agency or Program
That Took the Adverse Action
Specified in This Report:
Adverse Action
Classification Code(s):
Date Action Was Taken:
Date Action Became Effective:
Length of Action:
Years:
Months:
Days:
Is Subject Automatically Reinstated After
Adverse Action Period Is Completed?:

EXCLUSION/DEBARMENT
CONVICTION RELATING TO CONTROLLED SUBSTANCES (66)

PROGRAM INTEGRITY INITIATIVE
EXCLUSION FROM A FEDERAL HEALTH CARE PROGRAM (1505)
10/10/2014
10/10/2014
SPECIFIC PERIOD
2

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: PRACTITIONER DIVERTED DRUGS FOR PERSONAL USE.
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:

12/05/2014

Date of Most Recent Change:

12/05/2014

This report is maintained under the provisions of: Section 1921
The information contained in this report is maintained by the National Practitioner Data Bank for restricted use under the
provisions of Section 1921 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.

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY

the

DataBank

DCN: 5950000090960775
Process Date: 12/05/2014
Page: 3
of
3
MANN, ANITTA
For authorized use by:
LICENSING BOARD

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

END OF REPORT

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY

the

DataBank

DCN: 5950000090960776
Process Date: 12/05/2014
Page: 1
of
2
FOOTCAREINC.
For authorized use by:
LICENSING BOARD

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

FOOTCAREINC.
LICENSING BOARD
EXCLUSION/DEBARMENT ACTION

Date of Action: 02/20/2014

Initial Action
- EXCLUSION FROM A FEDERAL HEALTH CARE
PROGRAM
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

Type of Adverse Action:
Basis for Action:
Name of Agency or Program
That Took the Adverse Action
Specified in This Report:
Adverse Action
Classification Code(s):
Date Action Was Taken:
Date Action Became Effective:
Length of Action:

Basis for Initial Action
- CONVICTION RELATING TO PATIENT ABUSE OR
NEGLECT
LICENSING BOARD
123 CEDAR LANE
ROCKVILLE, MD 20857-0001
JANET DOE
BOARD OFFICIAL
(555) 555-5555
INITIAL
FOOTCAREINC.
5600 FISHERS LN
ROCKVILLE, MD 20852-1750
CHIROPRACTIC GROUP/PRACTICE (361)
MANN, ANITTA
111111111

SL89, MD

FOOTCAREINC2

SUBJECT IS SUBSIDIARY OF AFFILIATE OR ASSOCIATE (600)
EXCLUSION/DEBARMENT
CONVICTION RELATING TO PATIENT ABUSE OR NEGLECT (63)

PROGRAM INTEGRITY
EXCLUSION FROM A FEDERAL HEALTH CARE PROGRAM (3505)
02/20/2014
02/20/2014
SPECIFIC PERIOD

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY

the

DataBank

DCN: 5950000090960776
Process Date: 12/05/2014
Page: 2
of
2
FOOTCAREINC.
For authorized use by:
LICENSING BOARD

P.O. Box 10832
Chantilly, VA 20153-0832
http://www.npdb.hrsa.gov
Years:
Months:
Days:
Is Subject Automatically Reinstated After
Adverse Action Period Is Completed?:
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:
X

1
6

YES

PRACTITIONER NEGLECTED PATIENT AND DID NOT MEET STANDARD
OF CARE.

Subject identified in Section B has appealed the reported adverse action.
Date of Appeal: 11/11/2014

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:

12/05/2014

Date of Most Recent Change:

12/05/2014

This report is maintained under the provisions of: Section 1921
The information contained in this report is maintained by the National Practitioner Data Bank for restricted use under the
provisions of Section 1921 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