Provider Demographics
NPI:1396000279
Name:PREMIER PODIATRY-EAST COBB
Entity Type:Organization
Organization Name:PREMIER PODIATRY-EAST COBB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:R
Authorized Official - Last Name:BEACH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-971-9820
Mailing Address - Street 1:1200 JOHNSON FERRY RD STE 150
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-5403
Mailing Address - Country:US
Mailing Address - Phone:770-693-0700
Mailing Address - Fax:770-971-9822
Practice Address - Street 1:1121 JOHNSON FERRY RD
Practice Address - Street 2:BUILDING 1, SUITE 215
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-5425
Practice Address - Country:US
Practice Address - Phone:770-693-0700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-07
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
213ES0103X
GA213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty