Healthcare Provider Details

I. General information

NPI: 1922272012
Provider Name (Legal Business Name): FOOT AND ANKLE CENTER OF AUGUSTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2008
Last Update Date: 04/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1142 DRUID PARK AVE
AUGUSTA GA
30904-5850
US

IV. Provider business mailing address

1142 DRUID PARK AVE
AUGUSTA GA
30904-5850
US

V. Phone/Fax

Practice location:
  • Phone: 706-739-0020
  • Fax: 706-739-0024
Mailing address:
  • Phone: 706-739-0020
  • Fax: 706-739-0024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number000619
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number000619
License Number StateGA

VIII. Authorized Official

Name: LATANYA FYNE
Title or Position: PHYSICIAN
Credential: MD
Phone: 706-739-0020