Provider Demographics
NPI:1144407180
Name:NORTH GA FOOT AND ANKLE SPEC
Entity Type:Organization
Organization Name:NORTH GA FOOT AND ANKLE SPEC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RUDOLF
Authorized Official - Middle Name:W
Authorized Official - Last Name:CISCO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-287-0606
Mailing Address - Street 1:1224 SHERWOOD PARK DR NE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501
Mailing Address - Country:US
Mailing Address - Phone:770-287-0606
Mailing Address - Fax:
Practice Address - Street 1:1224 SHERWOOD PARK DR NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501
Practice Address - Country:US
Practice Address - Phone:770-287-0606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00409274AMedicaid
U20478Medicare UPIN
GA0745890001Medicare NSC
GA48SCBCJMedicare PIN