Provider Demographics
NPI:1679642516
Name:PREMIER FOOT AND ANKLE CENTER LLC
Entity Type:Organization
Organization Name:PREMIER FOOT AND ANKLE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEANINE
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:678-610-5988
Mailing Address - Street 1:1430 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-9111
Mailing Address - Country:US
Mailing Address - Phone:678-610-5988
Mailing Address - Fax:678-610-5976
Practice Address - Street 1:1430 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-9111
Practice Address - Country:US
Practice Address - Phone:678-610-5988
Practice Address - Fax:678-610-5976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001020213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5697310001Medicare NSC