Healthcare Provider Details

I. General information

NPI: 1013174457
Provider Name (Legal Business Name): SOUTHERN PODIATRY GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 12/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 LOVE AVE SUITE B
TIFTON GA
31794-4071
US

IV. Provider business mailing address

2718 N OAK ST
VALDOSTA GA
31602-1781
US

V. Phone/Fax

Practice location:
  • Phone: 229-382-5599
  • Fax:
Mailing address:
  • Phone:
  • 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: AVIS GRIFFIN
Title or Position: OFFICE MANAGER
Credential:
Phone: 229-242-3668