MEDICARE: DPM BRISSETT NRGA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	POD000950	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	48SCIQW	OTHER	GA	MEDICARE

General Provider Information

NPI Number	:	1326040114
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DPM BRISSETT NRGA LLC

Provider Business Mailing Address
First Line	:	5124 GROVE FIELD PT
Second Line	:
City	:	LITHONIA
State	:	GA
Zip	:	30038-2387
Country	:	US
Telephone Number	:	646-721-2072
Fax Number	:	866-678-9749

Provider Business Practice Location Address
First Line	:	5124 GROVE FIELD PT
Second Line	:
City	:	LITHONIA
State	:	GA
Zip	:	30038-2387
Country	:	US
Telephone Number	:	646-721-2072
Fax Number	:	866-678-9749

Authorized Official
Title or Position	:	DPM
Name	:	DR. ROBERT P BRISSETT
Credential	:	DPM
Telephone Number	:	646-721-2072

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	08/22/2020

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