1083789176 NPI number — PREMIER ORTHOPAEDICS & SPORTS MEDICINE, PLC

Table of content: (NPI 1083789176)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083789176 NPI number — PREMIER ORTHOPAEDICS & SPORTS MEDICINE, PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PREMIER ORTHOPAEDICS & SPORTS MEDICINE, PLC
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:
6
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:
1083789176
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 370
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORTSON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31808-0370
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-324-6661
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5651 FRIST BLVD
Provider Second Line Business Practice Location Address:
SUITE 515
Provider Business Practice Location Address City Name:
HERMITAGE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37076-2054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-889-3501
Provider Business Practice Location Address Fax Number:
615-889-3349
Provider Enumeration Date:
11/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BENCHWICK
Authorized Official First Name:
AMY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF CREDENTIALING
Authorized Official Telephone Number:
706-324-6661

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0922510006 . This is a "MEDICARE DME" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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