Provider Demographics
NPI:1588922306
Name:GEORGIA ORTHOPEDICS AND SPORTS MEDICINE,LLC
Entity type:Organization
Organization Name:GEORGIA ORTHOPEDICS AND SPORTS MEDICINE,LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-788-6534
Mailing Address - Street 1:4181 HOSPITAL DR NE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-2541
Mailing Address - Country:US
Mailing Address - Phone:770-788-6534
Mailing Address - Fax:770-788-7658
Practice Address - Street 1:4181 HOSPITAL DR NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2541
Practice Address - Country:US
Practice Address - Phone:770-788-6534
Practice Address - Fax:770-788-7658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-30
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
202G702667OtherMEDICARE PTAN
GA003126546AMedicaid