Provider Demographics
NPI:1114169703
Name:EDG SPORTS MEDICINE,INC
Entity type:Organization
Organization Name:EDG SPORTS MEDICINE,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:GAINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-296-5005
Mailing Address - Street 1:1230 BRIARVISTA WAY
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329
Mailing Address - Country:US
Mailing Address - Phone:404-296-5005
Mailing Address - Fax:404-296-5058
Practice Address - Street 1:2801 N DECATUR RD
Practice Address - Street 2:SUITE 200
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5949
Practice Address - Country:US
Practice Address - Phone:404-296-5005
Practice Address - Fax:404-296-5058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1857363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty