Provider Demographics
NPI:1881888287
Name:ELAINE ALLEN DPM
Entity type:Organization
Organization Name:ELAINE ALLEN DPM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-926-6686
Mailing Address - Street 1:203 WOODPARK PL
Mailing Address - Street 2:SUITE B-200
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-3705
Mailing Address - Country:US
Mailing Address - Phone:770-926-6686
Mailing Address - Fax:770-926-6635
Practice Address - Street 1:203 WOODPARK PL
Practice Address - Street 2:SUITE B-200
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-3705
Practice Address - Country:US
Practice Address - Phone:770-926-6686
Practice Address - Fax:770-926-6635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000744213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA393136OtherBCBS
0000163909413OtherUHC
323715OtherWELLCARE
175445029OtherTRICARE
3641408OtherAETNA HMO
GA00698167DMedicaid
P00240565OtherRAILROAD MEDICARE
4572029OtherAETNA
323715OtherWELLCARE
GA393136OtherBCBS