1851602429 NPI number — NORTH GEORGIA SPINE AND INTERVENTIONAL ORTHOPEDICS LLC

Table of content: (NPI 1851602429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851602429 NPI number — NORTH GEORGIA SPINE AND INTERVENTIONAL ORTHOPEDICS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH GEORGIA SPINE AND INTERVENTIONAL ORTHOPEDICS 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:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1851602429
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1897 HIGHWAY 211 NW STE 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOSCHTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30548-3514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-253-3341
Provider Business Mailing Address Fax Number:
770-307-0306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1897 HIGHWAY 211 NW STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOSCHTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30548-3514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-253-3341
Provider Business Practice Location Address Fax Number:
770-307-0306
Provider Enumeration Date:
06/29/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JABATI
Authorized Official First Name:
SALLU
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
678-559-4526

Provider Taxonomy Codes

  • Taxonomy code: 208VP0014X , with the licence number:  058527 , 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: 712681970B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1235104431 . This is a "NPI INDIVIDUAL" identifier . This identifiers is of the category "OTHER".