Basic Information
| Provider Information | |||||||||
| NPI: | 1144407180 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH GA FOOT AND ANKLE SPEC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1224 SHERWOOD PARK DR NE | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702870606 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1224 SHERWOOD PARK DR NE | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702870606 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2008 | ||||||||
| LastUpdateDate: | 01/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | CISCO | ||||||||
| AuthorizedOfficialFirstName: | RUDOLF | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 7702870606 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00409274A | 05 | GA | MEDICAID |