Basic Information
| Provider Information | |||||||||
| NPI: | 1912443201 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VILLAGE PODIATRY GROUP, LLC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VILLAGE PODIATRY CENTERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 900 CIRCLE 75 PKWY. | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303393084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784262171 | ||||||||
| FaxNumber: | 4044461957 | ||||||||
| Practice Location | |||||||||
| Address1: | 1224 SHERWOOD PARK DR NE | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702870606 | ||||||||
| FaxNumber: | 7702870159 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2017 | ||||||||
| LastUpdateDate: | 01/11/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HILSEN | ||||||||
| AuthorizedOfficialFirstName: | MITCHELL | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | C.O.O. | ||||||||
| AuthorizedOfficialTelephone: | 6784262171 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EXTREMITY HEALTHCARE, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.