NPIMap

Organization Active NPI

Modern Podiatry, LLC

  • Podiatric Clinic/Center
  • McDonough, GA
National Provider Identifier
1811538390
Registry record updated May 13, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Podiatric Clinic/CenterTaxonomy code 261QP1100X
Legal business name
MODERN PODIATRY, LLC
Practice address
366 Racetrack Rd
McDonough, GA 30252-1022
Phone
(470) 781-5585
NPI assigned
Oct 4, 2019
Last updated
May 13, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 13, 2024

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

Authorized official

Name
Dr. Kibibi Wanzu, DPMNPI 1043689623
Title
Owner
Phone
(470) 781-5585

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

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

Addresses

Primary practice location

366 Racetrack Rd
McDonough, GA 30252-1022

Mailing address

1270 Highway 314
Fayetteville, GA 30214-5449
Phone (813) 300-4449

Other identifiers 1

IdentifierTypeStateIssuer
003233587AMedicaidGA

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL www.modpodga.com

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200421003261 GA Part B Supplier - Clinic/Group Practice 0345670980 Receives reassigned benefits from 6 practitioners
Practice locations: Griffin, GA; McDonough, GA; Newnan, GA

National Provider Directory

National Provider Directory
Tax ID family
Modern Podiatry LLC3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

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

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1570147200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1715558400000",
    "number": "1811538390",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1270 HIGHWAY 314",
            "city": "FAYETTEVILLE",
            "state": "GA",
            "postal_code": "302145449",
            "telephone_number": "813-300-4449"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "366 RACETRACK RD",
            "city": "MCDONOUGH",
            "state": "GA",
            "postal_code": "302521022",
            "telephone_number": "470-781-5585"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MODERN PODIATRY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-10-04",
        "last_updated": "2024-05-13",
        "certification_date": "2024-05-13",
        "status": "A",
        "authorized_official_last_name": "WANZU",
        "authorized_official_first_name": "KIBIBI",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "470-781-5585",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DPM"
    },
    "taxonomies": [
        {
            "code": "261QP1100X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Podiatric",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "003233587A",
            "state": "GA"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "www.modpodga.com",
            "affiliation": "N",
            "endpointDescription": "website",
            "address_1": "366 Racetrack Rd",
            "city": "McDonough",
            "state": "GA",
            "country_code": "US",
            "postal_code": "302521022",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in McDonough, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 13, 2024; 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.