Provider Demographics
NPI:1154568582
Name:SOUTHEAST PODIATRY
Entity type:Organization
Organization Name:SOUTHEAST PODIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CLOUS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-852-7035
Mailing Address - Street 1:3225 SHALLOWFORD RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-1266
Mailing Address - Country:US
Mailing Address - Phone:770-675-7904
Mailing Address - Fax:770-675-7906
Practice Address - Street 1:3225 SHALLOWFORD RD
Practice Address - Street 2:SUITE 200
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-1266
Practice Address - Country:US
Practice Address - Phone:770-675-7904
Practice Address - Fax:770-675-7906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-07
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001011261Q00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No335E00000XSuppliersProsthetic/Orthotic Supplier