1063953149 NPI number — EFFINGHAM ORTHOPEDIC PRACTICE LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063953149 NPI number — EFFINGHAM ORTHOPEDIC PRACTICE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EFFINGHAM ORTHOPEDIC PRACTICE 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:
EFFINGHAM CHATHAM SPORTS MEDICINE
Provider Other Organization Name Type Code:
3
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:
1063953149
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
459 HIGHWAY 119 S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31329-3021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-754-0175
Provider Business Mailing Address Fax Number:
912-754-6395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
613 TOWNE PARK DR W
Provider Second Line Business Practice Location Address:
SUITE 303-304
Provider Business Practice Location Address City Name:
RINCON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31326-5182
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-355-6615
Provider Business Practice Location Address Fax Number:
912-351-0645
Provider Enumeration Date:
03/09/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BAKER-WITT
Authorized Official First Name:
FRANCINE
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO & NURSING HOME ADMINISTRATOR
Authorized Official Telephone Number:
912-754-0142

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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