Provider Demographics
NPI:1740499664
Name:FAMILY FOOT CARE OF STATESBORO
Entity type:Organization
Organization Name:FAMILY FOOT CARE OF STATESBORO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:SKELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:912-489-3668
Mailing Address - Street 1:PO BOX 886
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30459-0886
Mailing Address - Country:US
Mailing Address - Phone:912-489-3668
Mailing Address - Fax:912-489-4795
Practice Address - Street 1:407 S ZETTEROWER AVE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-7137
Practice Address - Country:US
Practice Address - Phone:912-489-3668
Practice Address - Fax:912-489-4795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000942213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7155Medicare ID - Type Unspecified
GAU87020Medicare UPIN