=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538373261
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN FOOT & ANKLE CENTER PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2007
-----------------------------------------------------
Last Update Date | 03/06/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 836 E 65TH ST # 9
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31405-4434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-355-3555
-----------------------------------------------------
Fax | 912-355-4499
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 836 E 65TH ST #9
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31405-4434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-355-3555
-----------------------------------------------------
Fax | 912-355-4499
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING REPRESENTATIVE
-----------------------------------------------------
Name | KATHY HODGES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 912-562-7092
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0131X
-----------------------------------------------------
Taxonomy Name | Foot Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------