Provider Demographics
NPI:1982921771
Name:SPORTS MEDICINE AND REHABILITATIVE THERAPY
Entity type:Organization
Organization Name:SPORTS MEDICINE AND REHABILITATIVE THERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-385-2333
Mailing Address - Street 1:PO BOX 5048
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-5048
Mailing Address - Country:US
Mailing Address - Phone:912-385-2333
Mailing Address - Fax:912-385-2350
Practice Address - Street 1:182 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-0401
Practice Address - Country:US
Practice Address - Phone:912-385-2333
Practice Address - Fax:912-385-2350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-03
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26436174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADQ8290OtherRAILROAD MEDICARE
GADQ8290OtherRAILROAD MEDICARE
GA4836750002Medicare NSC