Provider Demographics
NPI:1215320098
Name:ATHENS ORTHOPEDIC CLINIC, PA
Entity type:Organization
Organization Name:ATHENS ORTHOPEDIC CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHOPEDIC SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:HANCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-549-1663
Mailing Address - Street 1:1765 OLD WEST BROAD ST
Mailing Address - Street 2:BLDG 2, STE 200
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2853
Mailing Address - Country:US
Mailing Address - Phone:706-549-1663
Mailing Address - Fax:706-546-8792
Practice Address - Street 1:125 KING AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6734
Practice Address - Country:US
Practice Address - Phone:706-549-1663
Practice Address - Fax:706-546-8792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-18
Last Update Date:2015-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300019603AMedicaid
GA300019603AMedicaid