Provider Demographics
NPI:1184292138
Name:SUWANEE FOOT AND ANKLE SPECIALISTS LLC
Entity type:Organization
Organization Name:SUWANEE FOOT AND ANKLE SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TOMMY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:TALLY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:470-589-1204
Mailing Address - Street 1:1300 PEACHTREE INDUSTRIAL BLVD STE 4105
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4541
Mailing Address - Country:US
Mailing Address - Phone:470-589-1204
Mailing Address - Fax:470-589-1465
Practice Address - Street 1:1300 PEACHTREE INDUSTRIAL BLVD STE 4105
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-4541
Practice Address - Country:US
Practice Address - Phone:470-589-1204
Practice Address - Fax:470-589-1465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-16
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003219790AMedicaid