Basic Information
Provider Information | |||||||||
NPI: | 1982677621 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HOLCOMB'S FOOT & LEG CLINIC OF CUMMING | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NORTH GA FOOT & ANKLE CLINIC | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 236 ATLANTA RD | ||||||||
Address2: |   | ||||||||
City: | CUMMING | ||||||||
State: | GA | ||||||||
PostalCode: | 300402610 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7708899596 | ||||||||
FaxNumber: | 7708899547 | ||||||||
Practice Location | |||||||||
Address1: | 620 J L WHITE DR | ||||||||
Address2: | STE 100 | ||||||||
City: | JASPER | ||||||||
State: | GA | ||||||||
PostalCode: | 30143 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6788800036 | ||||||||
FaxNumber: | 6784937051 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/13/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HINTZE | ||||||||
AuthorizedOfficialFirstName: | BRET | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 7708899596 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DPM | ||||||||
NPICertificationDate: |   |
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 | 52866606002 | 01 | GA | BCBS | OTHER | 5168230004 | 01 | GA | DEMRC | OTHER |