Basic Information
| Provider Information | |||||||||
| NPI: | 1972576379 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOLCOMB'S FOOT & LEG CLINIC OF CUMMING | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CUMMING FOOT & LEG CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 236 ATLANTA ROAD | ||||||||
| Address2: | |||||||||
| City: | CUMMING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708899596 | ||||||||
| FaxNumber: | 7708899547 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 OAKSIDE LANE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6788800036 | ||||||||
| FaxNumber: | 6784937051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HINTZE | ||||||||
| AuthorizedOfficialFirstName: | BRET | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7708899596 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 000925 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 52866606009 | 01 | BCBS | OTHER | 5168230001 | 01 | GA | DMERC | OTHER |