Provider Demographics
NPI:1154728871
Name:CARROLLTON ORTHOPAEDIC CLINIC, PC
Entity type:Organization
Organization Name:CARROLLTON ORTHOPAEDIC CLINIC, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:
Authorized Official - Last Name:FLECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-601-5220
Mailing Address - Street 1:150 CLINIC AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4401
Mailing Address - Country:US
Mailing Address - Phone:678-601-5220
Mailing Address - Fax:
Practice Address - Street 1:705 DALLAS HWY
Practice Address - Street 2:SUITE 301
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1247
Practice Address - Country:US
Practice Address - Phone:678-601-5220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARROLLTON ORTHOPAEDIC CLINIC, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-24
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1356483747Medicare UPIN