Healthcare Provider Details

I. General information

NPI: 1306017728
Provider Name (Legal Business Name): STEPHEN A. BYRNE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2008
Last Update Date: 09/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 RIVERSTONE DR
CANTON GA
30114-5256
US

IV. Provider business mailing address

224 RIVERSTONE DR
CANTON GA
30114-5256
US

V. Phone/Fax

Practice location:
  • Phone: 770-479-4011
  • Fax: 770-809-5011
Mailing address:
  • Phone: 770-479-4011
  • Fax: 770-809-5011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number000515
License Number StateGA

VIII. Authorized Official

Name: DR. STEPHEN A BYRNE
Title or Position: DOCTOR/OWNER
Credential: D.P.M.
Phone: 770-479-4011