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General NPI Number Information
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NPI Number | 1497984397
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Entity Type | Organization
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Legal Business Name | SOUTHERN PODIATRY FOOT AND ANKLE, PLLC
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Dates
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Enumeration Date | 07/13/2009
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Last Update Date | 12/12/2024
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Provider Practice Location Address
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Address Line | 8000 MADISON BLVD STE D102-341
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City | MADISON
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State | AL
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Zip | 35758-2031
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Country | US
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Telephone | 312-752-7713
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Fax |
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Provider Business Mailing Address
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Address Line | 1311 GRANDEVIEW BLVD APT 1928
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City | HUNTSVILLE
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State | AL
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Zip | 35824-2408
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Country | US
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Telephone | 312-752-7713
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Fax |
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Authorized Official
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Title or Position | CPCS
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Name | ELYSE N TILLER
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Credential |
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Telephone | 615-956-7919
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0131X
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Taxonomy Name | Foot Surgery Podiatrist
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License Number | 299
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License Number State | AL
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