Form 16 Health Plan Action

the

DataBank

DCN: 5950000090960769
Process Date: 12/03/2014
Page: 1
of
3
MANN, ANNITA
For authorized use by:
WESTPORT HEALTHCARE

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

MANN, ANNITA
WESTPORT HEALTHCARE
HEALTH PLAN ACTION

Date of Action: 12/03/2014

Initial Action
- CONTRACT TERMINATION

A. REPORTING
ENTITY

- CLINICAL PRIVILEGES RESTRICTED, SUSPENDED OR
REVOKED BY ANOTHER HOSPITAL OR HEALTH CARE
FACILITY

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

WESTPORT HEALTHCARE
12447 W CARVER ST
DURHAM, NC 14052
DEVELOPER
DEVELOPER
(703) 555-1212
INITIAL
MANN, ANNITA
FEMALE
11/01/1982
FOOTCAREINC

CHIROPRACTIC GROUP/PRACTICE (361)
5600 FISHERS LN
ROCKVILLE, MD 20852-1750
NO
***-**-1111

UNIVERSITY OF THE FOOT (2002)
PODIATRIST

FOOTCAREINC

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY

the

DataBank

DCN: 5950000090960769
Process Date: 12/03/2014
Page: 2
of
3
MANN, ANNITA
For authorized use by:
WESTPORT HEALTHCARE

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

Type of Adverse Action: HEALTH PLAN ACTION
Basis for Action: CLINICAL PRIVILEGES RESTRICTED, SUSPENDED OR REVOKED BY
ANOTHER HOSPITAL OR HEALTH CARE FACILITY (A8)
Name of Agency or Program
That Took the Adverse Action
Specified in This Report: ABCD
Adverse Action
Classification Code(s): CONTRACT TERMINATION (1920)
Date Action Was Taken: 12/03/2014
Date Action Became Effective: 12/03/2014
Length of Action: INDEFINITE
Total Amount of Monetary Penalty,
Assessment and/or Restitution: $ 1.00
Is Subject Automatically Reinstated After
Adverse Action Period Is Completed?: YES
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: PROVIDED BAD FOOT CARE.

C. INFORMATION
REPORTED

X

Subject identified in Section B has appealed the reported adverse action.
Date of Appeal: 12/03/2014

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:

12/03/2014

Date of Most Recent Change:

12/03/2014

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.

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY

the

DataBank

DCN: 5950000090960769
Process Date: 12/03/2014
Page: 3
of
3
MANN, ANNITA
For authorized use by:
WESTPORT HEALTHCARE

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: 5950000090960770
Process Date: 12/03/2014
Page: 1
of
2
FOOTCAREINC
For authorized use by:
WESTPORT HEALTHCARE

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

FOOTCAREINC
WESTPORT HEALTHCARE
HEALTH PLAN ACTION

Date of Action: 12/03/2014

Initial Action
- CONTRACT TERMINATION

A. REPORTING
ENTITY

- DEBARMENT FROM FEDERAL OR STATE PROGRAM

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

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:

WESTPORT HEALTHCARE
12447 W CARVER ST
DURHAM, NC 14052
DEVELOPER
DEVELOPER
(703) 555-1212
INITIAL
FOOTCAREINC
5600 FISHERS LN
ROCKVILLE, MD 20852-1750
CHIROPRACTIC GROUP/PRACTICE (361)
MANN, ANNITA
111111111

SL89, MD

FOOTCAREINC3

HEALTH PLAN ACTION
DEBARMENT FROM FEDERAL OR STATE PROGRAM (82)

ABCD
CONTRACT TERMINATION (3920)
12/03/2014
12/03/2014
PERMANENT

CONFIDENTIAL DOCUMENT - FOR AUTHORIZED USE ONLY

the

DataBank

DCN: 5950000090960770
Process Date: 12/03/2014
Page: 2
of
2
FOOTCAREINC
For authorized use by:
WESTPORT HEALTHCARE

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

Total Amount of Monetary Penalty,
Assessment and/or Restitution: $ 1.00
Is Subject Automatically Reinstated After
Adverse Action Period Is Completed?: YES
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: PROVIDED BAD FOOT CARE.
X

Subject identified in Section B has appealed the reported adverse action.
Date of Appeal: 12/03/2014

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:

12/03/2014

Date of Most Recent Change:

12/03/2014

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