Provider Demographics
NPI:1427523919
Name:TALLY, TOMMY LEE (DPM)
Entity type:Individual
Prefix:DR
First Name:TOMMY
Middle Name:LEE
Last Name:TALLY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 PEACHTREE INDUSTRIAL BLVD STE 4105
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4541
Mailing Address - Country:US
Mailing Address - Phone:470-589-1204
Mailing Address - Fax:470-598-1465
Practice Address - Street 1:1300 PEACHTREE INDUSTRIAL BLVD STE 4105
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-4541
Practice Address - Country:US
Practice Address - Phone:470-589-1204
Practice Address - Fax:470-589-1465
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-10
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD001388213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003219790AMedicaid