Provider Demographics
NPI:1528166113
Name:SOUTHERN BONE & JOINT AMBULATORY SURGICAL CENTER, LLC
Entity type:Organization
Organization Name:SOUTHERN BONE & JOINT AMBULATORY SURGICAL CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER AND AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:BALDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-5935
Mailing Address - Street 1:1755 HIGHWAY 34 E
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-5631
Mailing Address - Country:US
Mailing Address - Phone:770-252-7510
Mailing Address - Fax:770-252-7512
Practice Address - Street 1:1755 HIGHWAY 34 E
Practice Address - Street 2:SUITE 1100
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-5631
Practice Address - Country:US
Practice Address - Phone:770-252-7510
Practice Address - Fax:770-252-7511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
111187ASCAMedicare ID - Type Unspecified