Basic Information
| Provider Information | |||||||||
| NPI: | 1891887311 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VILLAGE PODIATRY GROUP, LLC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 CIRCLE 75 PKWY. | ||||||||
| Address2: | STE. 900 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303393084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703840284 | ||||||||
| FaxNumber: | 7704327638 | ||||||||
| Practice Location | |||||||||
| Address1: | 3655 HOWELL FERRY RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | DULUTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300963186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704978283 | ||||||||
| FaxNumber: | 7704978285 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 08/19/2014 | ||||||||
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| AuthorizedOfficialLastName: | HELFMAN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | N. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| 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 | 213E00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | CL1536 | 01 | GA | RAILROAD MEDICARE GROUP # | OTHER |