J. Palmer    Branch    DPM
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000004317
NPI
1346244985
Tax ID
260348793
Effective Date
4/1/2012
Last Updated
9/27/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
4705 Lawrenceville Highway Northwest Suite
Lilburn, GA 30047
United States
County
Gwinnett
Phone
7709218800 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Podiatry
Map
Address