Healthcare Provider Details

I. General information

NPI: 1912443201
Provider Name (Legal Business Name): VILLAGE PODIATRY GROUP, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2017
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 SHERWOOD PARK DR NE
GAINESVILLE GA
30501-3445
US

IV. Provider business mailing address

900 CIRCLE 75 PKWY. SUITE 900
ATLANTA GA
30339-3084
US

V. Phone/Fax

Practice location:
  • Phone: 770-287-0606
  • Fax: 770-287-0159
Mailing address:
  • Phone: 678-426-2171
  • Fax: 404-446-1957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: MITCHELL P. HILSEN
Title or Position: C.O.O.
Credential: DPM
Phone: 678-426-2171