Provider Demographics
NPI:1962560649
Name:ADVANCE SPINAL CARE OF GEORGIA
Entity type:Organization
Organization Name:ADVANCE SPINAL CARE OF GEORGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BONNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-475-8221
Mailing Address - Street 1:11940 ALPHARETTA HWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-2003
Mailing Address - Country:US
Mailing Address - Phone:770-475-8221
Mailing Address - Fax:770-619-9606
Practice Address - Street 1:11940 ALPHARETTA HWY
Practice Address - Street 2:SUITE 110
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-2003
Practice Address - Country:US
Practice Address - Phone:770-475-8221
Practice Address - Fax:770-619-9606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA621111302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA08CBCMPMedicare PIN
GA25BBFZJMedicare PIN
GA13BDBWR01Medicare PIN
GA20NCCSCMedicare PIN