Basic Information
| Provider Information | |||||||||
| NPI: | 1770539801 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAPHAEL | ||||||||
| FirstName: | ALLEN | ||||||||
| MiddleName: | TERENCE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.M. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 900 CIRCLE 75 PKWY. SE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300803084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784262171 | ||||||||
| FaxNumber: | 4044461957 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 HIGHLANDS PARKWAY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SMYRNA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300825196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703195502 | ||||||||
| FaxNumber: | 7704349010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 10/15/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | POD001050 | GA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 52212173-001 | 01 | GA | BC/BS, SMYRNA | OTHER | 761921467P | 05 | GA | MEDICAID | 761921467G | 05 | GA | MEDICAID | 52212173-002 | 01 | GA | BC/BS DOUGLASVILLE | OTHER | 761921467A | 05 | GA | MEDICAID | 946888 | 01 | GA | BLUE CROSS BLUE SHIELD GA | OTHER | 5284933 | 01 | GA | CIGNA | OTHER | 761921467J | 05 | GA | MEDICAID | 581994261 | 01 | GA | GREAT WEST HEALTHCARE | OTHER | 761921467C | 05 | GA | MEDICAID |