Provider Demographics
NPI:1144593948
Name:AUGUSTA PODIATRIC MEDICINE & SURGERY INC.
Entity Type:Organization
Organization Name:AUGUSTA PODIATRIC MEDICINE & SURGERY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:CCHELTREE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:540-886-6424
Mailing Address - Street 1:100-A MACTANLY PLACE
Mailing Address - Street 2:
Mailing Address - City:STAUNTON
Mailing Address - State:VA
Mailing Address - Zip Code:24401
Mailing Address - Country:US
Mailing Address - Phone:540-886-6424
Mailing Address - Fax:540-213-0491
Practice Address - Street 1:100 MACTANLY PL
Practice Address - Street 2:SUITE A
Practice Address - City:STAUNTON
Practice Address - State:VA
Practice Address - Zip Code:24401-2383
Practice Address - Country:US
Practice Address - Phone:540-886-6424
Practice Address - Fax:540-213-0491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-10
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000705213E00000X, 261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatricGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
029891OtherANTHEM ID