Provider Demographics
NPI:1336311620
Name:PEACHTREE PODIATRY GROUP
Entity Type:Organization
Organization Name:PEACHTREE PODIATRY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-384-0284
Mailing Address - Street 1:300 VILLAGE GREEN CIR SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-3476
Mailing Address - Country:US
Mailing Address - Phone:770-384-0284
Mailing Address - Fax:770-432-7638
Practice Address - Street 1:2193 NORTHLAKE PKWY
Practice Address - Street 2:SUITE 114
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4116
Practice Address - Country:US
Practice Address - Phone:770-938-5974
Practice Address - Fax:770-939-7393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty