MEDICARE: NORTHEAST GEORGIA ORTHOPAEDICS & SPORTS MEDICINE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician

General Provider Information

NPI Number	:	1093725327
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST GEORGIA ORTHOPAEDICS & SPORTS MEDICINE, LLC

Provider Business Mailing Address
First Line	:	655 JESSE JEWELL PKWY SE
Second Line	:	SUITE B
City	:	GAINESVILLE
State	:	GA
Zip	:	30501-3722
Country	:	US
Telephone Number	:	770-532-7092
Fax Number	:	770-536-0383

Provider Business Practice Location Address
First Line	:	5737 THOMPSON MILL RD
Second Line	:
City	:	HOSCHTON
State	:	GA
Zip	:	30548-4001
Country	:	US
Telephone Number	:	770-532-7092
Fax Number	:	770-536-0383

Authorized Official
Title or Position	:	MEMBER/PHYSICIAN
Name	:	DONALD ROGER WILLERS
Credential	:	M.D.
Telephone Number	:	770-532-7092

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	08/22/2020

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