Provider Demographics
NPI:1013174457
Name:SOUTHERN PODIATRY GROUP, PC
Entity Type:Organization
Organization Name:SOUTHERN PODIATRY GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-242-3668
Mailing Address - Street 1:2718 N OAK ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1781
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:820 LOVE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-4071
Practice Address - Country:US
Practice Address - Phone:229-382-5599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300026567AMedicaid
GAGRP81Medicare PIN
GA300026567AMedicaid
GA0266960001Medicare NSC