Healthcare Provider Details

I. General information

NPI: 1356483747
Provider Name (Legal Business Name): CARROLLTON ORTHOPAEDIC CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 CLINIC AVE SUITE 101
CARROLLTON GA
30117-4401
US

IV. Provider business mailing address

150 CLINIC AVE SUITE 101
CARROLLTON GA
30117-4401
US

V. Phone/Fax

Practice location:
  • Phone: 770-834-0873
  • Fax:
Mailing address:
  • Phone: 770-834-0873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number16340
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number055277
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number048440
License Number StateGA

VIII. Authorized Official

Name: MELANIE JORDAN
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 770-834-0873