Healthcare Provider Details

I. General information

NPI: 1306876198
Provider Name (Legal Business Name): GEORGIA SPINE AND BRAIN, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1676 MULKEY RD SUITE A
AUSTELL GA
30106-1170
US

IV. Provider business mailing address

1676 MULKEY RD SUITE A
AUSTELL GA
30106-1170
US

V. Phone/Fax

Practice location:
  • Phone: 678-838-6600
  • Fax: 678-838-6602
Mailing address:
  • Phone: 678-838-6600
  • Fax: 678-838-6602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: OMAR JIMENEZ
Title or Position: OWNER
Credential: MD
Phone: 678-838-6600