Provider Demographics
NPI:1982836862
Name:SPORTS MEDICINE OF GWINNETT
Entity type:Organization
Organization Name:SPORTS MEDICINE OF GWINNETT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:MAUGHON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-813-8888
Mailing Address - Street 1:3855 PLEASANT HILL RD
Mailing Address - Street 2:SUITE 470
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-1407
Mailing Address - Country:US
Mailing Address - Phone:770-813-8888
Mailing Address - Fax:770-813-0007
Practice Address - Street 1:3855 PLEASANT HILL RD
Practice Address - Street 2:SUITE 470
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-1407
Practice Address - Country:US
Practice Address - Phone:770-813-8888
Practice Address - Fax:770-813-0007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-11
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty