Healthcare Provider Details

I. General information

NPI: 1184292138
Provider Name (Legal Business Name): SUWANEE FOOT AND ANKLE SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 PEACHTREE INDUSTRIAL BLVD STE 4105
SUWANEE GA
30024-4541
US

IV. Provider business mailing address

1300 PEACHTREE INDUSTRIAL BLVD STE 4105
SUWANEE GA
30024-4541
US

V. Phone/Fax

Practice location:
  • Phone: 470-589-1204
  • Fax: 470-589-1465
Mailing address:
  • Phone: 470-589-1204
  • Fax: 470-589-1465

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. TOMMY LEE TALLY JR.
Title or Position: PHYSICIAN
Credential: DPM
Phone: 470-589-1204