Provider Demographics
NPI:1528241791
Name:ORTHOPAEDIC SPECIALTIES OF ATLANTA, INC.
Entity type:Organization
Organization Name:ORTHOPAEDIC SPECIALTIES OF ATLANTA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:BOCO
Authorized Official - Phone:770-335-7989
Mailing Address - Street 1:331 CURIE DR
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-2264
Mailing Address - Country:US
Mailing Address - Phone:770-619-0615
Mailing Address - Fax:
Practice Address - Street 1:331 CURIE DR
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-2264
Practice Address - Country:US
Practice Address - Phone:770-619-0615
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA51335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA230948743BMedicaid
GA230948743BMedicaid