Healthcare Provider Details

I. General information

NPI: 1306960836
Provider Name (Legal Business Name): MARIETTA PODIATRY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 VANN ST NE
MARIETTA GA
30060-7249
US

IV. Provider business mailing address

165 VANN ST NE
MARIETTA GA
30060-7249
US

V. Phone/Fax

Practice location:
  • Phone: 770-422-9856
  • Fax: 770-984-0303
Mailing address:
  • Phone: 770-422-9856
  • Fax: 770-984-0303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateGA

VIII. Authorized Official

Name: DR. GLYN E. LEWIS
Title or Position: CEO
Credential: DPM
Phone: 770-422-9856