Provider Demographics
NPI:1861541344
Name:ANTIOCH MEDICAL ASSOCIATES
Entity type:Organization
Organization Name:ANTIOCH MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ALPHONSO
Authorized Official - Last Name:DANDY
Authorized Official - Suffix:SR
Authorized Official - Credentials:OD
Authorized Official - Phone:912-927-8011
Mailing Address - Street 1:9104 MIDDLEGROUND RD
Mailing Address - Street 2:STE 2
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-4302
Mailing Address - Country:US
Mailing Address - Phone:912-927-8011
Mailing Address - Fax:912-927-8311
Practice Address - Street 1:9104 MIDDLEGROUND RD
Practice Address - Street 2:STE 2
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-4302
Practice Address - Country:US
Practice Address - Phone:912-927-8011
Practice Address - Fax:912-927-8311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000860213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000817242CMedicaid
GA000817242CMedicaid
GAU75411Medicare UPIN
GA5691140001Medicare NSC
GAGRP7610Medicare PIN