Provider Demographics
NPI:1154793339
Name:GEORGE S TELLAM
Entity type:Organization
Organization Name:GEORGE S TELLAM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:SAWDAY
Authorized Official - Last Name:TELLAM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:904-269-9595
Mailing Address - Street 1:981 KINGSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4742
Mailing Address - Country:US
Mailing Address - Phone:904-269-9595
Mailing Address - Fax:904-264-5211
Practice Address - Street 1:309 KINGSLEY LAKE DR
Practice Address - Street 2:# 901
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-3047
Practice Address - Country:US
Practice Address - Phone:904-269-9595
Practice Address - Fax:904-264-5211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-27
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 1636213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1750319026OtherINDIVIDUAL NPI
FL0683220001Medicare NSC
FL87904Medicare PIN