Provider Demographics
NPI:1831575034
Name:ACTIVE ANKLE & FOOT CARE SPECIALIST
Entity type:Organization
Organization Name:ACTIVE ANKLE & FOOT CARE SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:INGIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:EL-KHASHAB
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:404-373-7004
Mailing Address - Street 1:PO BOX 71
Mailing Address - Street 2:
Mailing Address - City:AVONDALE ESTATES
Mailing Address - State:GA
Mailing Address - Zip Code:30002-0071
Mailing Address - Country:US
Mailing Address - Phone:404-373-7004
Mailing Address - Fax:404-373-7008
Practice Address - Street 1:6335 HOSPITAL PARKWAY
Practice Address - Street 2:SUITE 305
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-5712
Practice Address - Country:US
Practice Address - Phone:404-373-7004
Practice Address - Fax:404-373-7008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-11
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAV05923Medicare UPIN
GA511I480043Medicare PIN
GA6139410001Medicare NSC