Basic Information
| Provider Information | |||||||||
| NPI: | 1336311620 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEACHTREE PODIATRY GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 VILLAGE GREEN CIR SE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SMYRNA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300803476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703840284 | ||||||||
| FaxNumber: | 7704327638 | ||||||||
| Practice Location | |||||||||
| Address1: | 2193 NORTHLAKE PKWY | ||||||||
| Address2: | SUITE 114 | ||||||||
| City: | TUCKER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300844116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709385974 | ||||||||
| FaxNumber: | 7709397393 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2008 | ||||||||
| LastUpdateDate: | 03/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | BANKS | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7703840284 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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.