Healthcare Provider Details

I. General information

NPI: 1356824585
Provider Name (Legal Business Name): ORTHO SPORT & SPINE PHYSICIANS AUGUSTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2018
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1306 TROUPE ST
AUGUSTA GA
30904-4799
US

IV. Provider business mailing address

5788 ROSWELL RD
ATLANTA GA
30328-4904
US

V. Phone/Fax

Practice location:
  • Phone: 706-842-4113
  • Fax:
Mailing address:
  • Phone: 678-783-7615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: WHITNEY GLOVER
Title or Position: CREDENTIALING
Credential:
Phone: 678-783-7615