Provider Demographics
NPI:1013061357
Name:WEST GEORGIA PODIATRY ASSOC.
Entity Type:Organization
Organization Name:WEST GEORGIA PODIATRY ASSOC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-832-3546
Mailing Address - Street 1:125 HISTORY DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3969
Mailing Address - Country:US
Mailing Address - Phone:770-832-3546
Mailing Address - Fax:770-832-3518
Practice Address - Street 1:125 HISTORY DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3969
Practice Address - Country:US
Practice Address - Phone:770-832-3546
Practice Address - Fax:770-832-3518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000434213ES0103X
GA000758213ES0103X
GA000478213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000672306AMedicaid
GA000133834AMedicaid
GA000133834AMedicaid
GAT86433Medicare UPIN
GAU59194Medicare UPIN