=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447362298
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY PODIATRY CENTER PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 11/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 95 BEL AIR DR
-----------------------------------------------------
City | STATESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30461-6879
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-489-8727
-----------------------------------------------------
Fax | 912-764-7882
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1106
-----------------------------------------------------
City | STATESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30459-1106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-489-8727
-----------------------------------------------------
Fax | 912-764-7882
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | DR. ROBERT WILLIAM CUSHNER
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 912-489-8727
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP1100X
-----------------------------------------------------
Taxonomy Name | Podiatric Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------