1558528190 NPI number — GEORGIA SPINE SPECIALISTS

Table of content: (NPI 1558528190)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558528190 NPI number — GEORGIA SPINE SPECIALISTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA SPINE SPECIALISTS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558528190
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/17/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3903 SOUTH COBB DR
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
SMYRNA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30080
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-838-6600
Provider Business Mailing Address Fax Number:
770-438-1477

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
51 GORDON RD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
JASPER
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30143-7105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-838-6600
Provider Business Practice Location Address Fax Number:
770-438-1477
Provider Enumeration Date:
05/21/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JIMENEZ
Authorized Official First Name:
MIGUEL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
678-838-6600

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  GA052966 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207XS0117X , with the licence number: GA052966 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 615972752B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 52062173007 . This is a "BCBS CV ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 615972752A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 805775515A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 52062173008 . This is a "BCBS AUSTELL ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 611911600 . This is a "US DOL ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: GRP7885 . This is a "MEDICARE GRP NUMBER" identifier . This identifiers is of the category "OTHER".