Basic Information
| Provider Information | |||||||||
| NPI: | 1508242546 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VILLAGE PODIATRY GROUP, LLC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | US CARDIOVASCULAR SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 CIRCLE 75 PKWY SE STE 900 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303393084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784262171 | ||||||||
| FaxNumber: | 4044461957 | ||||||||
| Practice Location | |||||||||
| Address1: | 1938 PEACHTREE RD NW | ||||||||
| Address2: | STE. L-5 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788312722 | ||||||||
| FaxNumber: | 6789995055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2015 | ||||||||
| LastUpdateDate: | 04/29/2016 | ||||||||
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| AuthorizedOfficialLastName: | HILSEN | ||||||||
| AuthorizedOfficialFirstName: | MITCHELL | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | C.O.O. | ||||||||
| AuthorizedOfficialTelephone: | 7703840284 | ||||||||
| 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 | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 207RI0011X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
No ID Information.