Provider Demographics
NPI:1962809129
Name:PREMIER ORTHOPAEDICS & SPORTS MEDICINE, PLC
Entity type:Organization
Organization Name:PREMIER ORTHOPAEDICS & SPORTS MEDICINE, PLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:FROMKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-494-3071
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:706-324-6661
Mailing Address - Fax:
Practice Address - Street 1:100 PHYSICIANS WAY
Practice Address - Street 2:SUITE 120
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37090-8102
Practice Address - Country:US
Practice Address - Phone:615-784-4336
Practice Address - Fax:615-784-4337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-03
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0922510013OtherMEDICARE DME