Basic Information
| Provider Information | |||||||||
| NPI: | 1922490366 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GA FOOT AND ANKLE INSTITUTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 310 EISENHOWER DR | ||||||||
| Address2: | BUILDING 7A | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314062632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123556503 | ||||||||
| FaxNumber: | 9123559837 | ||||||||
| Practice Location | |||||||||
| Address1: | 10164 FORD AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | RICHMOND HILL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313243949 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123556503 | ||||||||
| FaxNumber: | 9123559837 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2015 | ||||||||
| LastUpdateDate: | 02/23/2015 | ||||||||
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| AuthorizedOfficialLastName: | VARNER | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9123556503 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GA FOOT AND ANKLE INSTITUTE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 885 | GA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000880514 | 05 | GA | MEDICAID |