Healthcare Provider Details

I. General information

NPI: 1154568582
Provider Name (Legal Business Name): SOUTHEAST PODIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2009
Last Update Date: 11/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 SHALLOWFORD RD SUITE 200
MARIETTA GA
30062-1266
US

IV. Provider business mailing address

3225 SHALLOWFORD RD SUITE 200
MARIETTA GA
30062-1266
US

V. Phone/Fax

Practice location:
  • Phone: 770-675-7904
  • Fax: 770-675-7906
Mailing address:
  • Phone: 770-675-7904
  • Fax: 770-675-7906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberPOD001011
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberPOD001011
License Number StateGA

VIII. Authorized Official

Name: DR. SUZANNE MARIE CLOUS
Title or Position: PODIATRIST
Credential: D.P.M.
Phone: 770-852-7035