Provider Demographics
NPI:1760670673
Name:MCDUFFIE PODIATRY AND WOUND CARE, PC
Entity Type:Organization
Organization Name:MCDUFFIE PODIATRY AND WOUND CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:S
Authorized Official - Last Name:HAVRILLA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:706-595-8787
Mailing Address - Street 1:544 W HILL ST
Mailing Address - Street 2:
Mailing Address - City:THOMSON
Mailing Address - State:GA
Mailing Address - Zip Code:30824-2117
Mailing Address - Country:US
Mailing Address - Phone:706-595-8787
Mailing Address - Fax:706-595-8757
Practice Address - Street 1:544 W HILL ST
Practice Address - Street 2:
Practice Address - City:THOMSON
Practice Address - State:GA
Practice Address - Zip Code:30824-2117
Practice Address - Country:US
Practice Address - Phone:706-595-8787
Practice Address - Fax:706-595-8757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000848213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10041458OtherAMERIGROUP
GA322007OtherWELLCARE OF GEORGIA
GA618552906AMedicaid
GAGRP6239OtherMEDICARE GROUP #
GA52773057-003OtherBLUE CROSS BLUE SHIELD GA
GA10581911OtherCIGNA
GA5467067OtherAETNA
GA48SCCNBMedicare PIN
GA618552906AMedicaid
GA52773057-003OtherBLUE CROSS BLUE SHIELD GA
GAGRP6239OtherMEDICARE GROUP #