Provider Demographics
NPI:1124152459
Name:FAMILY FOOT AND ANKLE CTR
Entity type:Organization
Organization Name:FAMILY FOOT AND ANKLE CTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:THEODORE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:478-390-2178
Mailing Address - Street 1:841 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-6756
Mailing Address - Country:US
Mailing Address - Phone:478-741-1192
Mailing Address - Fax:478-741-0029
Practice Address - Street 1:407 BARRINGTON PT
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31220-8754
Practice Address - Country:US
Practice Address - Phone:478-390-2178
Practice Address - Fax:478-471-0104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000753213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
480025693OtherRAILROAD MEDICARE
GA00655322AMedicaid
480018494OtherRAILROAD MEDICARE
GA00655322AMedicaid
5143350001Medicare NSC