=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073797908
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANKLE & FOOT SPECIALIST
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2007
-----------------------------------------------------
Last Update Date | 01/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 GORDON AVE
-----------------------------------------------------
City | THOMASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31792-6611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-226-1338
-----------------------------------------------------
Fax | 229-226-4888
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 GORDON AVE
-----------------------------------------------------
City | THOMASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31792-6611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-226-1338
-----------------------------------------------------
Fax | 229-226-4888
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. E. RICHARD GROVES
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 229-226-1338
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | PO 551
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------