Provider Demographics
NPI:1376614826
Name:GAINESVILLE FOOT AND ANKLE SURGERY CENTER, PC
Entity Type:Organization
Organization Name:GAINESVILLE FOOT AND ANKLE SURGERY CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-536-4702
Mailing Address - Street 1:1975 BEVERLY RD
Mailing Address - Street 2:SUITE-B
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-2034
Mailing Address - Country:US
Mailing Address - Phone:770-536-4702
Mailing Address - Fax:770-536-9394
Practice Address - Street 1:1975 BEVERLY RD
Practice Address - Street 2:SUITE-B
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2034
Practice Address - Country:US
Practice Address - Phone:770-536-4702
Practice Address - Fax:770-536-9394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA069-279261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA51005007-002OtherBLUE CROSS-BLUE SHIELD
GA069-279OtherSTATA LICENSE
GA111239ASCAMedicare ID - Type Unspecified
GAY06541Medicare UPIN