Healthcare Provider Details

I. General information

NPI: 1093993735
Provider Name (Legal Business Name): HABERSHAM PODIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 05/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134B MARKET CORNERS DR
CORNELIA GA
30531-5766
US

IV. Provider business mailing address

PO BOX 191
CORNELIA GA
30531-0191
US

V. Phone/Fax

Practice location:
  • Phone: 706-776-3132
  • Fax: 706-776-2836
Mailing address:
  • Phone: 706-776-3132
  • Fax: 706-776-2836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number000902
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number4624980001
License Number StateGA

VIII. Authorized Official

Name: DR. JANA M ROSE
Title or Position: OWNER
Credential: DPM
Phone: 706-776-3132