1265053110 NPI number — SPORTS MEDICINE SOUTH OF GWINNETT 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 1265053110 NPI number — SPORTS MEDICINE SOUTH OF GWINNETT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPORTS MEDICINE SOUTH OF GWINNETT 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:
1265053110
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 SUMMIT BLVD STE 1000
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKHAVEN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30319-6415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-851-8000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 RIVERSIDE PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAWRENCEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30043-5925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-237-3475
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/01/2020

Additional Information

Authorized Official

Authorized Official Last Name:
HERNANDEZ
Authorized Official First Name:
JORGE
Authorized Official Middle Name:
Authorized Official Title or Position:
VP/CCO
Authorized Official Telephone Number:
404-851-8000

Provider Taxonomy Codes

  • Taxonomy code: 207XX0005X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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