Provider Demographics
NPI:1750525515
Name:ELITE FOOT AND ANKLE SPECIALIST-PC
Entity type:Organization
Organization Name:ELITE FOOT AND ANKLE SPECIALIST-PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:IVIE
Authorized Official - Last Name:EJAIFE-AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:678-360-7939
Mailing Address - Street 1:1468 SPRINGLEAF CIR SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-2400
Mailing Address - Country:US
Mailing Address - Phone:678-360-7939
Mailing Address - Fax:
Practice Address - Street 1:1468 SPRINGLEAF CIR SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-2400
Practice Address - Country:US
Practice Address - Phone:678-360-7939
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001084213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty