Basic Information
| Provider Information | |||||||||
| NPI: | 1285727438 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VILLAGE PODIATRY GROUP, LLC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 CIRCLE 75 PKWY. SE | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303393084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703840284 | ||||||||
| FaxNumber: | 7704327638 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 GREYSTONE POWER BLVD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301570908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709437877 | ||||||||
| FaxNumber: | 7709438809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 10/21/2014 | ||||||||
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| AuthorizedOfficialLastName: | HELFMAN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | N. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6784262171 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EXTREMITY HEALTHCARE, INC. | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | CL1536 | 01 | GA | RAILROAD MEDICARE GRP NBR | OTHER |