NPIMap

Organization Active NPI

Marietta Podiatry Group

  • Podiatric Clinic/Center
  • Marietta, GA
National Provider Identifier
1487638318
Registry record updated Jan 5, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Podiatric Clinic/CenterTaxonomy code 261QP1100X
Legal business name
MARIETTA PODIATRY GROUP
Practice address
165 Vann St NE
Marietta, GA 30060-7249
Phone
(770) 422-9856
Fax
(770) 984-0303
NPI assigned
Dec 5, 2005
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 5, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Glyn E Lewis, DPM
Title
Ceo
Phone
(770) 422-9856

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Podiatric Clinic/Center 261QP1100X Primary

Addresses

Primary practice location

165 Vann St NE
Marietta, GA 30060-7249

Mailing address

165 Vann St NE
Marietta, GA 30060-7249
Phone (770) 422-9856

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040419001215 GA Part B Supplier - Clinic/Group Practice 5092700922 Receives reassigned benefits from 4 practitioners
1 other NPI on this enrollment
Practice locations: Marietta, GA
O20100930053160 GA DME Supplier - Physician - Podiatry 5092700922 Practice locations: Marietta, GA

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Marietta Podiatry Group2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1133740800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1325721600000",
    "number": "1487638318",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "165 VANN ST NE",
            "city": "MARIETTA",
            "state": "GA",
            "postal_code": "300607249",
            "telephone_number": "770-422-9856",
            "fax_number": "770-984-0303"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "165 VANN ST NE",
            "city": "MARIETTA",
            "state": "GA",
            "postal_code": "300607249",
            "telephone_number": "770-422-9856",
            "fax_number": "770-984-0303"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MARIETTA PODIATRY GROUP",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-12-05",
        "last_updated": "2012-01-05",
        "status": "A",
        "authorized_official_last_name": "LEWIS",
        "authorized_official_first_name": "GLYN",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "770-422-9856",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DPM"
    },
    "taxonomies": [
        {
            "code": "261QP1100X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Podiatric",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Marietta, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 5, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.