Provider Demographics
NPI:1699785790
Name:NORTHEAST ORTHOPEDIC CLINIC PC
Entity type:Organization
Organization Name:NORTHEAST ORTHOPEDIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNUTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-547-7417
Mailing Address - Street 1:507 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35901-5216
Mailing Address - Country:US
Mailing Address - Phone:256-547-7417
Mailing Address - Fax:256-547-7414
Practice Address - Street 1:507 S 4TH ST
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901-5216
Practice Address - Country:US
Practice Address - Phone:256-547-7417
Practice Address - Fax:256-547-7414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALD705Medicare ID - Type UnspecifiedGROUP MEIDCARE NUMBER