1518096122 NPI number — DOMINION ORTHOPAEDIC CLINIC, LLC

Table of content: (NPI 1518096122)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518096122 NPI number — DOMINION ORTHOPAEDIC CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:
DOMINION ORTHOPAEDIC CLINIC, LLC

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:
1518096122

Entity Type Code:
Organization

Replacement NPI:

Last Update Date:
01/04/2023

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5555 PEACHTREE DUNWOODY RD NE

Provider Second Line Business Mailing Address:
SUITE 215

Provider Business Mailing Address City Name:
ATLANTA

Provider Business Mailing Address State Name:
GA

Provider Business Mailing Address Postal Code:
30342-1703

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
770-455-4009

Provider Business Mailing Address Fax Number:
770-455-4065

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6 CONCOURSE PKWY STE 260

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
ATLANTA

Provider Business Practice Location Address State Name:
GA

Provider Business Practice Location Address Postal Code:
30328-6117

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
770-455-4009

Provider Business Practice Location Address Fax Number:
770-455-4065

Provider Enumeration Date:
03/02/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CLARK

Authorized Official First Name:
RUTH

Authorized Official Middle Name:

Authorized Official Title or Position:
PRACTICE ADMINISTRATOR

Authorized Official Telephone Number:
770-455-4009

Provider Taxonomy Codes

Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Taxonomy code: 174400000X , with the licence number: 037539 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .