Provider Demographics
NPI:1427127778
Name:FITNESS FORUM OF GEORGIA
Entity type:Organization
Organization Name:FITNESS FORUM OF GEORGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR PHYSICAL THERAPY
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:MSPT
Authorized Official - Phone:404-236-0808
Mailing Address - Street 1:993 F JOHNSON FERRY ROAD NE
Mailing Address - Street 2:SUITE 330
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342
Mailing Address - Country:US
Mailing Address - Phone:404-236-0808
Mailing Address - Fax:404-256-0709
Practice Address - Street 1:993 F JOHNSON FERRY ROAD NE
Practice Address - Street 2:SUITE 330
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-236-0808
Practice Address - Fax:404-256-0709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA65BBDGS224Z00000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA611446156001OtherTRICARE
GADB0566OtherMEDICARE RAILROAD
GAGRP4332Medicare PIN