Provider Demographics
NPI:1942270657
Name:ADVANCED FOOT & WOUND CENTER OF CAMDEN CO PC
Entity Type:Organization
Organization Name:ADVANCED FOOT & WOUND CENTER OF CAMDEN CO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DIADRA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:912-882-3338
Mailing Address - Street 1:PO BOX 600
Mailing Address - Street 2:
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548-0600
Mailing Address - Country:US
Mailing Address - Phone:912-882-3338
Mailing Address - Fax:912-882-0526
Practice Address - Street 1:102 LAKESHORE DR STE C
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3874
Practice Address - Country:US
Practice Address - Phone:912-882-3338
Practice Address - Fax:912-882-0526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-25
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000932213E00000X
FLP02758213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
7101735OtherAETNA
GAGRP7234Medicare PIN
GA5638810001Medicare NSC