Provider Demographics
NPI:1487638318
Name:MARIETTA PODIATRY GROUP
Entity Type:Organization
Organization Name:MARIETTA PODIATRY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GLYN
Authorized Official - Middle Name:E
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-422-9856
Mailing Address - Street 1:165 VANN ST NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-7249
Mailing Address - Country:US
Mailing Address - Phone:770-422-9856
Mailing Address - Fax:770-984-0303
Practice Address - Street 1:165 VANN ST NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7249
Practice Address - Country:US
Practice Address - Phone:770-422-9856
Practice Address - Fax:770-984-0303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0940220002Medicare NSC