Provider Demographics
NPI:1952727992
Name:GENESIS FOOT & LEG SPECIALISTS, LLC
Entity Type:Organization
Organization Name:GENESIS FOOT & LEG SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALISTS
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-777-6519
Mailing Address - Street 1:836 EAST 65TH STREET
Mailing Address - Street 2:UNIT 34
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404
Mailing Address - Country:US
Mailing Address - Phone:912-777-6519
Mailing Address - Fax:912-777-6584
Practice Address - Street 1:21563 WYHTE HARDEE BLVD
Practice Address - Street 2:
Practice Address - City:HARDEEVILLE
Practice Address - State:SC
Practice Address - Zip Code:29927
Practice Address - Country:US
Practice Address - Phone:912-777-6519
Practice Address - Fax:912-777-6584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC625213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGPD625Medicaid