Provider Demographics
NPI:1922238047
Name:S.E. FAMILY FOOT & ANKLE CENTER LLC
Entity Type:Organization
Organization Name:S.E. FAMILY FOOT & ANKLE CENTER LLC
Other - Org Name:FAMILY FOOT AND ANKLE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:P
Authorized Official - Last Name:THEODORE
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:478-741-1192
Mailing Address - Street 1:841 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-6756
Mailing Address - Country:US
Mailing Address - Phone:478-741-1192
Mailing Address - Fax:478-471-0029
Practice Address - Street 1:841 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-6756
Practice Address - Country:US
Practice Address - Phone:478-741-1192
Practice Address - Fax:478-471-0029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-23
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000753213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA006555322AMedicaid
GA480025693OtherRAILROAD MEDICARE
GA006555322AMedicaid