=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689868085
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACHILLES FOOT & ANKLE SPECIALIST
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2007
-----------------------------------------------------
Last Update Date | 03/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1580 MARS HILL RD SUITE A
-----------------------------------------------------
City | WATKINSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30677-4836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-769-9200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 463
-----------------------------------------------------
City | WATKINSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30677-0012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-769-9200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICIAN
-----------------------------------------------------
Name | MARK WILLIAM SHAFFER
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 706-769-9200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | POD000585
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------