Basic Information
| Provider Information | |||||||||
| NPI: | 1083876304 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREENBRIAR FOOT & ANKLE CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 VILLAGE GREEN CIRCLE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SMYRNA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703840284 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4480 COVINGTON HIGHWAY | ||||||||
| Address2: | SUITE A | ||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042884117 | ||||||||
| FaxNumber: | 4042888451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2008 | ||||||||
| LastUpdateDate: | 06/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | TODD | ||||||||
| AuthorizedOfficialFirstName: | TOBI | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4042884117 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GREENBRIAR FOOT & ANKLE CENTER LLC | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.