1821263963 NPI number — ALLIED ANKLE & FOOTCARE CENTERS PC

Table of content: (NPI 1821263963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821263963 NPI number — ALLIED ANKLE & FOOTCARE CENTERS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALLIED ANKLE & FOOTCARE 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:
1821263963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 491658
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAWRENCEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30049-0028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-255-0420
Provider Business Mailing Address Fax Number:
770-255-0425

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 HURRICANE SHOALS RD NE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LAWRENCEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30046-4454
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-277-7373
Provider Business Practice Location Address Fax Number:
770-277-1755
Provider Enumeration Date:
04/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BOUCHARD
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
LOUIS
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
770-255-0420

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  POD000418 , 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: GRP446 . This is a "MEDICARE GROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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