Healthcare Provider Details

I. General information

NPI: 1639641384
Provider Name (Legal Business Name): SPINE CENTER ATLANTA NORTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2018
Last Update Date: 12/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3540 DULUTH PARK LN STE 120
DULUTH GA
30096-3200
US

IV. Provider business mailing address

3161 HOWELL MILL RD NW STE 310
ATLANTA GA
30327-2132
US

V. Phone/Fax

Practice location:
  • Phone: 404-458-9956
  • Fax:
Mailing address:
  • Phone: 404-351-5812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: STEVEN WEIDLER
Title or Position: CFO
Credential:
Phone: 404-351-5812