Basic Information
| Provider Information | |||||||||
| NPI: | 1740306059 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOOT AND LEG CLINIC, PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | AMBULATORY FOOT AND LEG SURGICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1652 MULKEY RD | ||||||||
| Address2: | |||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705440444 | ||||||||
| FaxNumber: | 7708748950 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 MULKEY RD | ||||||||
| Address2: | |||||||||
| City: | AUSTELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301061186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705440444 | ||||||||
| FaxNumber: | 7708748950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 08/13/2013 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | JANA | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7705440444 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 0042221A | 05 | GA | MEDICAID |