Healthcare Provider Details

I. General information

NPI: 1093481251
Provider Name (Legal Business Name): ORTHOXPRESS OF GEORGIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2021
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 IVEY RD NW STE 1401
ACWORTH GA
30101-4007
US

IV. Provider business mailing address

206 OXFORD RD
NEW ALBANY MS
38652-3115
US

V. Phone/Fax

Practice location:
  • Phone: 470-648-8108
  • Fax: 470-648-8109
Mailing address:
  • Phone: 662-534-2227
  • Fax: 662-534-2330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER C BULLOCK
Title or Position: PRESIDENT
Credential:
Phone: 662-534-2227