Provider Demographics
NPI:1114381027
Name:GEORGIA RECONSTRUCTIVE FOOT AND ANKLE CENTER LLC
Entity Type:Organization
Organization Name:GEORGIA RECONSTRUCTIVE FOOT AND ANKLE CENTER LLC
Other - Org Name:GEORGIA RECONSTRUCTIVE FOOT AND ANKLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:678-770-5838
Mailing Address - Street 1:293 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:WINDER
Mailing Address - State:GA
Mailing Address - Zip Code:30680-2155
Mailing Address - Country:US
Mailing Address - Phone:770-867-4110
Mailing Address - Fax:
Practice Address - Street 1:293 N BROAD ST
Practice Address - Street 2:
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-2155
Practice Address - Country:US
Practice Address - Phone:770-867-4110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-06
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001293213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPOD001293OtherLICENSE
GA7562450001Medicare NSC