Provider Demographics
NPI:1306275748
Name:ATHENS SPINE WELLNESS CENTER LLC
Entity type:Organization
Organization Name:ATHENS SPINE WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MEGDAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-425-2400
Mailing Address - Street 1:830 KING AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2889
Mailing Address - Country:US
Mailing Address - Phone:706-425-2400
Mailing Address - Fax:706-425-2410
Practice Address - Street 1:830 KING AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2889
Practice Address - Country:US
Practice Address - Phone:706-425-2400
Practice Address - Fax:706-425-2410
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ATHENS SPINE CENTER PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA152208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA537122616AMedicaid
GA373133496AMedicaid
GA000275646BMedicaid
GA373133496AMedicaid
GA000275646BMedicaid
GAGRP 7615Medicare PIN
GAA72646Medicare UPIN