Provider Demographics
NPI:1275708315
Name:ALLIED ANKLE & FOOTCARE CENTERS PC
Entity Type:Organization
Organization Name:ALLIED ANKLE & FOOTCARE CENTERS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:BOUCHARD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-255-0424
Mailing Address - Street 1:PO BOX 491658
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30049-0028
Mailing Address - Country:US
Mailing Address - Phone:770-255-0425
Mailing Address - Fax:770-255-0425
Practice Address - Street 1:2784 N DECATUR RD
Practice Address - Street 2:SUITE 150
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5903
Practice Address - Country:US
Practice Address - Phone:404-298-6050
Practice Address - Fax:404-508-0648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000418213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP446OtherMEDICARE GROUP
GAGRP446OtherMEDICARE GROUP