Provider Demographics
NPI:1447331350
Name:CROSSROADS PODIATRY & INGROWN NAIL CENTER INC
Entity type:Organization
Organization Name:CROSSROADS PODIATRY & INGROWN NAIL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EVERETT
Authorized Official - Middle Name:J
Authorized Official - Last Name:MASON
Authorized Official - Suffix:III
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-251-8940
Mailing Address - Street 1:3231 HWY 34 EAST
Mailing Address - Street 2:SUITE C
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265
Mailing Address - Country:US
Mailing Address - Phone:770-251-8940
Mailing Address - Fax:770-251-5685
Practice Address - Street 1:3231 HWY 34 EAST
Practice Address - Street 2:SUITE C
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265
Practice Address - Country:US
Practice Address - Phone:770-251-8940
Practice Address - Fax:770-251-5685
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000688213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPOD000688OtherLICENSE
GA00558874BMedicaid
GA00558874BMedicaid
GAPOD000688OtherLICENSE
GAU40655Medicare UPIN
GA00558874BMedicaid