Provider Demographics
NPI:1356500573
Name:JOHN J LAND IV PC
Entity Type:Organization
Organization Name:JOHN J LAND IV PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:LAND
Authorized Official - Suffix:IV
Authorized Official - Credentials:DPM
Authorized Official - Phone:706-278-5558
Mailing Address - Street 1:1107 BROADRICK DR
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2592
Mailing Address - Country:US
Mailing Address - Phone:706-278-5558
Mailing Address - Fax:706-278-6334
Practice Address - Street 1:1107 BROADRICK DR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2592
Practice Address - Country:US
Practice Address - Phone:706-278-5558
Practice Address - Fax:706-278-6334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000679213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA480027427OtherRAIL ROAD MEDICARE
GA1440694OtherUMWA
GA000828385AMedicaid
TN3351905OtherMEDICARE
TN3124909OtherBLUE CROSS/ BLUE SHIELD
GA52432145OtherBLUE CROSS/ BLUE SHIELD
GAU33730Medicare UPIN
GA1440694OtherUMWA