Anthony    Gordon    DPM
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000004393
NPI
1386602464
Tax ID
582420213
Effective Date
4/1/2012
Last Updated
9/30/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
68.00
Location Details
Address
270 Hawthorne Avenue Suite B
Athens, GA 30606
United States
County
Clarke
Phone
7062089977 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Podiatry
Map
Address