1356598593 NPI number — PROVIDENCE FOOT & ANKLE CENTERS PC

Table of content: (NPI 1356598593)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356598593 NPI number — PROVIDENCE FOOT & ANKLE CENTERS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVIDENCE FOOT & ANKLE CENTERS PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356598593
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3886 PRINCETON LAKES WAY SW
Provider Second Line Business Mailing Address:
SUITE 140A
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30331-5511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-745-4224
Provider Business Mailing Address Fax Number:
770-790-4752

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1110 MARSHALL RD
Provider Second Line Business Practice Location Address:
WELLNESS CENTER
Provider Business Practice Location Address City Name:
GREENWOOD
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29646-4216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-896-3338
Provider Business Practice Location Address Fax Number:
770-790-4752
Provider Enumeration Date:
08/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ATKINSON-SNEED
Authorized Official First Name:
ADRIENNE
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
770-745-4224

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213EP1101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ER0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9277 . This is a "MEDICARE GROUP PTAN FOR SC (PALMETTO GBA)" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: DQ9090 . This is a "MEDICARE RR (PALMETTO GBA) SC" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: PENDING . This is a "DME (PALMETTO GBA NSC) GROUP PTAN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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