Healthcare Provider Details

I. General information

NPI: 1992479596
Provider Name (Legal Business Name): ST. MARY SPINE AND SPORT INJURIES REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2021
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 E US HIGHWAY 80 STE D
BLOOMINGDALE GA
31302-9356
US

IV. Provider business mailing address

502 E US HIGHWAY 80 STE D
BLOOMINGDALE GA
31302-9356
US

V. Phone/Fax

Practice location:
  • Phone: 912-999-7275
  • Fax: 912-988-3748
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: NOHA RAOUF SOLIMAN
Title or Position: PROVIDER/OWNER
Credential: DO
Phone: 912-508-8828