Provider Demographics
NPI:1588842686
Name:NORTH GA PODIATRIC MEDICINE AND SURGERY
Entity type:Organization
Organization Name:NORTH GA PODIATRIC MEDICINE AND SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIDLOW
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-386-1389
Mailing Address - Street 1:958A JOE FRANK HARRIS PKWY SE STE 106
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-2129
Mailing Address - Country:US
Mailing Address - Phone:770-386-1389
Mailing Address - Fax:770-386-4894
Practice Address - Street 1:958A JOE FRANK HARRIS PKWY SE STE 106
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-2129
Practice Address - Country:US
Practice Address - Phone:770-386-1389
Practice Address - Fax:770-386-4894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0508570001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU19472Medicare UPIN
GA0508570001Medicare NSC