Provider Demographics
NPI:1730365834
Name:DR. GEORGE S TELLAM
Entity type:Organization
Organization Name:DR. GEORGE S TELLAM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:TELLAM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:904-269-6565
Mailing Address - Street 1:981 KINGSLEY AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4742
Mailing Address - Country:US
Mailing Address - Phone:904-269-9595
Mailing Address - Fax:904-264-5211
Practice Address - Street 1:981 KINGSLEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4742
Practice Address - Country:US
Practice Address - Phone:904-269-9595
Practice Address - Fax:904-264-5211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-18
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1636213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========OtherTRICARE
FL0683220001Medicare NSC