Provider Demographics
NPI:1548439672
Name:SOUTH GEORGIA FAMILY FOOT INSTITUE PC
Entity type:Organization
Organization Name:SOUTH GEORGIA FAMILY FOOT INSTITUE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEKLE
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:229-227-1997
Mailing Address - Street 1:510 GORDON AVE
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-6646
Mailing Address - Country:US
Mailing Address - Phone:229-227-1997
Mailing Address - Fax:229-227-9389
Practice Address - Street 1:510 GORDON AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6646
Practice Address - Country:US
Practice Address - Phone:229-227-1997
Practice Address - Fax:229-227-9389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000695213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU45075Medicare UPIN
GA1092080001Medicare NSC
GA48SCBKRMedicare PIN