Healthcare Provider Details

I. General information

NPI: 1144407180
Provider Name (Legal Business Name): NORTH GA FOOT AND ANKLE SPEC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 SHERWOOD PARK DR NE
GAINESVILLE GA
30501
US

IV. Provider business mailing address

1224 SHERWOOD PARK DR NE
GAINESVILLE GA
30501
US

V. Phone/Fax

Practice location:
  • Phone: 770-287-0606
  • Fax:
Mailing address:
  • Phone: 770-287-0606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. RUDOLF W CISCO
Title or Position: OWNER DOCTOR
Credential: DPM
Phone: 770-287-0606