1538569637 NPI number — ORTHOSQUAD LLC

Table of content: (NPI 1538569637)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538569637 NPI number — ORTHOSQUAD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORTHOSQUAD 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:
1538569637
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
980 BIRMINGHAM RD STE 501-299
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30004-4417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-790-2922
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1031 CAMBRIDGE SQ STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALPHARETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30009-1869
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-790-2922
Provider Business Practice Location Address Fax Number:
866-576-7014
Provider Enumeration Date:
08/26/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
TRACY
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
404-790-2922

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  47 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 003169168B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003169168A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com