Basic Information
| Provider Information | |||||||||
| NPI: | 1760649602 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FITZGERALD | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | HUDSON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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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: | 132 RIVERSTONE TER STE 101 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788800036 | ||||||||
| FaxNumber: | 4044814427 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2008 | ||||||||
| LastUpdateDate: | 01/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 626 | SC | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | 0103301013 | VA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213E00000X | POD001364 | GA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | PD6265 | 05 | SC | MEDICAID |