Provider Demographics
NPI:1326844689
Name:ORTHOSPORTS1ST GA
Entity type:Organization
Organization Name:ORTHOSPORTS1ST GA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CCO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WIMBISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-701-6386
Mailing Address - Street 1:PO BOX 830525
Mailing Address - Street 2:DEPARTMENT# OWC 24
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35283-0525
Mailing Address - Country:US
Mailing Address - Phone:470-790-0725
Mailing Address - Fax:470-754-0882
Practice Address - Street 1:4300 BELLS FERRY RD NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-1304
Practice Address - Country:US
Practice Address - Phone:470-790-0725
Practice Address - Fax:470-754-0882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-19
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty