Provider Demographics
NPI:1306183280
Name:FAMILY FOOT AND ANKLE CENTER
Entity Type:Organization
Organization Name:FAMILY FOOT AND ANKLE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:P
Authorized Official - Last Name:THEODORE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:478-741-1192
Mailing Address - Street 1:841 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-6756
Mailing Address - Country:US
Mailing Address - Phone:478-741-1192
Mailing Address - Fax:478-741-0029
Practice Address - Street 1:841 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-6756
Practice Address - Country:US
Practice Address - Phone:478-741-1192
Practice Address - Fax:478-741-0029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-11
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000753213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA48SCBPDMedicare UPIN