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General NPI Number Information
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NPI Number | 1013174457
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Entity Type | Organization
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Legal Business Name | SOUTHERN PODIATRY GROUP, PC
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Dates
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Enumeration Date | 05/22/2008
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Last Update Date | 12/01/2009
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Provider Practice Location Address
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Address Line | 820 LOVE AVE SUITE B
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City | TIFTON
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State | GA
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Zip | 31794-4071
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Country | US
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Telephone | 229-382-5599
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Fax |
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Provider Business Mailing Address
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Address Line | 2718 N OAK ST
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City | VALDOSTA
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State | GA
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Zip | 31602-1781
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | AVIS GRIFFIN
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Credential |
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Telephone | 229-242-3668
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number |
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License Number State |
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