Basic Information
| Provider Information | |||||||||
| NPI: | 1881888287 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELAINE ALLEN DPM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FOOT & ANKLE CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 203 WOODPARK PL | ||||||||
| Address2: | SUITE B-200 | ||||||||
| City: | WOODSTOCK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301883705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709266686 | ||||||||
| FaxNumber: | 7709266635 | ||||||||
| Practice Location | |||||||||
| Address1: | 203 WOODPARK PL | ||||||||
| Address2: | SUITE B-200 | ||||||||
| City: | WOODSTOCK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301883705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709266686 | ||||||||
| FaxNumber: | 7709266635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2007 | ||||||||
| LastUpdateDate: | 10/01/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | ELAINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PODIATRIST/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7709266686 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DPM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | POD000744 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 393136 | 01 | GA | BCBS | OTHER | 0000163909413 | 01 | UHC | OTHER | 323715 | 01 | WELLCARE | OTHER | 175445029 | 01 | TRICARE | OTHER | 3641408 | 01 | AETNA HMO | OTHER | 00698167D | 05 | GA | MEDICAID | P00240565 | 01 | RAILROAD MEDICARE | OTHER | 4572029 | 01 | AETNA | OTHER |