Healthcare Provider Details

I. General information

NPI: 1023502846
Provider Name (Legal Business Name): ATLANTA SPINE ANESTHESIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2018
Last Update Date: 06/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 PEACHTREE PARK DR NE STE 200
ATLANTA GA
30309
US

IV. Provider business mailing address

PO BOX 865700
ORLANDO FL
32886-5700
US

V. Phone/Fax

Practice location:
  • Phone: 678-369-6934
  • Fax:
Mailing address:
  • Phone: 888-337-3509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: DR. CARL NOBACK
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 888-337-3509