1215220090 NPI number — GEORGIA PODIATRY, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215220090 NPI number — GEORGIA PODIATRY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA PODIATRY, INC
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:
1215220090
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5205 STILESBORO RD.
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
KENNESAW
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30152-7760
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-310-0540
Provider Business Mailing Address Fax Number:
678-310-0538

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5205 STILESBORO RD NW STE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNESAW
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30152-7765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-310-0540
Provider Business Practice Location Address Fax Number:
678-310-0538
Provider Enumeration Date:
05/26/2011

Additional Information

Authorized Official

Authorized Official Last Name:
STEPHENS
Authorized Official First Name:
MARY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
678-310-0540

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  000937 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1679548168 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1215220090 . This is a "NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 520666344 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: DR8420 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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