Healthcare Provider Details

I. General information

NPI: 1053466615
Provider Name (Legal Business Name): GEORGIA SPORTS ORTHOPEDIC SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1466 JESSE JEWELL PKWY SE
GAINESVILLE GA
30501-3852
US

IV. Provider business mailing address

1466 JESSE JEWELL PKWY SE
GAINESVILLE GA
30501-3852
US

V. Phone/Fax

Practice location:
  • Phone: 770-532-0503
  • Fax: 770-532-2284
Mailing address:
  • Phone: 770-532-0503
  • Fax: 770-532-2284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: HEATHER A COUCH
Title or Position: CMA, ADMINISRTATIVE
Credential:
Phone: 770-532-0503