Provider Demographics
NPI:1033285457
Name:ATHENS PODIATRY, P.C.
Entity type:Organization
Organization Name:ATHENS PODIATRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAURO
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROSSI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:706-546-7417
Mailing Address - Street 1:3320 OLD JEFFERSON RD
Mailing Address - Street 2:BUILDING 300, SUITE A
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30607-1400
Mailing Address - Country:US
Mailing Address - Phone:706-546-7417
Mailing Address - Fax:706-612-1310
Practice Address - Street 1:3320 OLD JEFFERSON RD
Practice Address - Street 2:BUILDING 300, SUITE A
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30607-1400
Practice Address - Country:US
Practice Address - Phone:706-546-7417
Practice Address - Fax:706-612-1310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000767213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000679533AMedicaid
GAU32554Medicare UPIN
GAGRP2468Medicare PIN
GA000679533AMedicaid