1760082077 NPI number — ORTHO SPORT AND SPINE PHYSICIANS DOUGLASVILLE

Table of content: MRS. MEGAN KENZIE OLLIS NC LMBT (NPI 1609589688)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760082077 NPI number — ORTHO SPORT AND SPINE PHYSICIANS DOUGLASVILLE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORTHO SPORT AND SPINE PHYSICIANS DOUGLASVILLE
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:
1760082077
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5788 ROSWELL RD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30328-4904
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-752-7246
Provider Business Mailing Address Fax Number:
770-234-5326

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6043 PRESTLEY MILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUGLASVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30134-2280
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-752-7246
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/27/2020

Additional Information

Authorized Official

Authorized Official Last Name:
BELTZHOOVER
Authorized Official First Name:
FAITH
Authorized Official Middle Name:
A
Authorized Official Title or Position:
BILLING DIRECTOR
Authorized Official Telephone Number:
678-752-7246

Provider Taxonomy Codes

  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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