Provider Demographics
NPI:1427079185
Name:NORTHEAST GEORGIA ORTHOPAEDICS & SPORTS MEDICINE, LLC
Entity type:Organization
Organization Name:NORTHEAST GEORGIA ORTHOPAEDICS & SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:WILLERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-532-7092
Mailing Address - Street 1:655 JESSE JEWELL PKWY SE
Mailing Address - Street 2:SUITE B
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3722
Mailing Address - Country:US
Mailing Address - Phone:770-532-7092
Mailing Address - Fax:770-536-0383
Practice Address - Street 1:655 JESSE JEWELL PKWY SE
Practice Address - Street 2:SUITE B
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3722
Practice Address - Country:US
Practice Address - Phone:770-532-7092
Practice Address - Fax:770-536-0383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP508Medicare ID - Type Unspecified