Healthcare Provider Details

I. General information

NPI: 1497984397
Provider Name (Legal Business Name): SOUTHERN PODIATRY FOOT AND ANKLE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2009
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 MADISON BLVD STE D102-341
MADISON AL
35758-2031
US

IV. Provider business mailing address

1311 GRANDEVIEW BLVD APT 1928
HUNTSVILLE AL
35824-2408
US

V. Phone/Fax

Practice location:
  • Phone: 312-752-7713
  • Fax:
Mailing address:
  • Phone: 312-752-7713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number299
License Number StateAL

VIII. Authorized Official

Name: ELYSE N TILLER
Title or Position: CPCS
Credential:
Phone: 615-956-7919