1265638381 NPI number — S.DEKALB FOOT & ANKLE SURGICAL CTR

Table of content: DR. KATHERINE FLAGG PH.D. PSYCHOLOGIST (NPI 1225006042)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265638381 NPI number — S.DEKALB FOOT & ANKLE SURGICAL CTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
S.DEKALB FOOT & ANKLE SURGICAL CTR
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:
6
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:
1265638381
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2889 S RAINBOW DR
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30034-1670
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-241-7848
Provider Business Mailing Address Fax Number:
404-241-2161

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
841 MULBERRY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31201-6756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-741-1192
Provider Business Practice Location Address Fax Number:
478-741-0029
Provider Enumeration Date:
06/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
THEODORE
Authorized Official First Name:
ROGER
Authorized Official Middle Name:
PETER
Authorized Official Title or Position:
PODIATRIST
Authorized Official Telephone Number:
404-241-7848

Provider Taxonomy Codes

  • Taxonomy code: 261QP1100X , with the licence number:  000753 , 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: 00655322A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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