Provider Demographics
NPI:1184819930
Name:EAST COBB PODIATRY SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:EAST COBB PODIATRY SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:LIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-977-8221
Mailing Address - Street 1:4439 ROSWELL RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-6452
Mailing Address - Country:US
Mailing Address - Phone:770-977-8221
Mailing Address - Fax:770-977-8222
Practice Address - Street 1:4439 ROSWELL RD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-6452
Practice Address - Country:US
Practice Address - Phone:770-977-8221
Practice Address - Fax:770-977-8222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11C0001132261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAX23487Medicare UPIN
GA111132ASCAMedicare PIN