Healthcare Provider Details

I. General information

NPI: 1073979621
Provider Name (Legal Business Name): ATLANTA SPINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2016
Last Update Date: 08/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1288 WELLBROOK CIR NE STE A
CONYERS GA
30012-8032
US

IV. Provider business mailing address

1288 WELLBROOK CIR NE STE A
CONYERS GA
30012-8032
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY FORD
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 678-369-6934