Provider Demographics
NPI:1376160309
Name:AMG PODIATRY LLC
Entity Type:Organization
Organization Name:AMG PODIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODEILL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:360-269-2106
Mailing Address - Street 1:1925 S FOLLETT WAY
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-0155
Mailing Address - Country:US
Mailing Address - Phone:360-269-2106
Mailing Address - Fax:
Practice Address - Street 1:4915 E BASELINE RD STE 121
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2969
Practice Address - Country:US
Practice Address - Phone:480-812-3668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-25
Last Update Date:2020-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty