Provider Demographics
NPI:1497984397
Name:SOUTHERN PODIATRY FOOT AND ANKLE, PLLC
Entity type:Organization
Organization Name:SOUTHERN PODIATRY FOOT AND ANKLE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CPCS
Authorized Official - Prefix:
Authorized Official - First Name:ELYSE
Authorized Official - Middle Name:N
Authorized Official - Last Name:TILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-956-7919
Mailing Address - Street 1:1311 GRANDEVIEW BLVD APT 1928
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35824-2408
Mailing Address - Country:US
Mailing Address - Phone:312-752-7713
Mailing Address - Fax:
Practice Address - Street 1:8000 MADISON BLVD STE D102-341
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-2031
Practice Address - Country:US
Practice Address - Phone:312-752-7713
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-13
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL299213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510-49599OtherBCBSAL
AL112600Medicaid