Provider Demographics
NPI:1376668020
Name:FAMILY PODIATRY CENTER PC
Entity Type:Organization
Organization Name:FAMILY PODIATRY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:CUSHNER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:912-489-8727
Mailing Address - Street 1:PO BOX 1106
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-1106
Mailing Address - Country:US
Mailing Address - Phone:912-489-8727
Mailing Address - Fax:912-764-7882
Practice Address - Street 1:1804 SEMINOLE DRIVE
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474
Practice Address - Country:US
Practice Address - Phone:912-537-9864
Practice Address - Fax:912-537-2914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2007000326261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric