Healthcare Provider Details

I. General information

NPI: 1386908184
Provider Name (Legal Business Name): PINNACLE ORTHOPAEDICS & SPORTS MEDICINE SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2012
Last Update Date: 10/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 COBB PARKWAY NW SUITE 309G
ACWORTH GA
30101-0000
US

IV. Provider business mailing address

300 TOWER ROAD SUITE 200
MARIETTA GA
30060-9403
US

V. Phone/Fax

Practice location:
  • Phone: 678-213-5717
  • Fax: 678-213-5723
Mailing address:
  • Phone: 770-427-5717
  • Fax: 770-514-6744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number31591
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number65285
License Number StateGA

VIII. Authorized Official

Name: DONNA L FISHER
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential: CAO
Phone: 770-429-7741