Provider Demographics
NPI:1124418918
Name:SOUTHWEST ATLANTA PODIATRY, LLC
Entity Type:Organization
Organization Name:SOUTHWEST ATLANTA PODIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:W
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:973-243-2666
Mailing Address - Street 1:3915 CASCADE RD SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-8512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3915 CASCADE RD SW
Practice Address - Street 2:SUITE 230
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-8512
Practice Address - Country:US
Practice Address - Phone:973-243-2666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-30
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD 1031213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5551005Medicaid
NJ142268Medicare UPIN
NJ334163Medicare PIN