Provider Demographics
NPI:1790931483
Name:PROVIDENCE FOOT & ANKLE CENTERS, P.C., INC.
Entity Type:Organization
Organization Name:PROVIDENCE FOOT & ANKLE CENTERS, P.C., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:
Authorized Official - First Name:ADRIENNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:ATKINSON-SNEED
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-745-4224
Mailing Address - Street 1:3886 PRINCETON LAKES WAY SW
Mailing Address - Street 2:SUITE 140A
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-5511
Mailing Address - Country:US
Mailing Address - Phone:770-745-4224
Mailing Address - Fax:770-790-4752
Practice Address - Street 1:865 THORNTON RD
Practice Address - Street 2:SUITE B
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-2607
Practice Address - Country:US
Practice Address - Phone:770-745-4224
Practice Address - Fax:770-790-4752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-13
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiologyGroup - Single Specialty
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511G700902OtherMEDICARE GA (CAHABA GBA) GROUP PTAN
6169580003OtherDME (PALMETTO GBA NSC) GROUP PTAN FOR THORNTON
DQ9092OtherMEDICARE RR (PALMETTO GBA) GROUP PTAN
6169580003OtherDME (PALMETTO GBA NSC) GROUP PTAN FOR THORNTON