Provider Demographics
NPI:1558528190
Name:GEORGIA SPINE SPECIALISTS
Entity type:Organization
Organization Name:GEORGIA SPINE SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-838-6600
Mailing Address - Street 1:3903 SOUTH COBB DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080
Mailing Address - Country:US
Mailing Address - Phone:678-838-6600
Mailing Address - Fax:770-438-1477
Practice Address - Street 1:51 GORDON RD
Practice Address - Street 2:SUITE 1
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-7105
Practice Address - Country:US
Practice Address - Phone:678-838-6600
Practice Address - Fax:770-438-1477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA052966207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA615972752BMedicaid
52062173007OtherBCBS CV ID
GA615972752AMedicaid
GA805775515AMedicaid
52062173008OtherBCBS AUSTELL ID
611911600OtherUS DOL ID
GRP7885OtherMEDICARE GRP NUMBER
52062173008OtherBCBS AUSTELL ID
GAG11962Medicare UPIN