Healthcare Provider Details

I. General information

NPI: 1558528190
Provider Name (Legal Business Name): GEORGIA SPINE SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2008
Last Update Date: 04/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 GORDON RD SUITE 1
JASPER GA
30143-7105
US

IV. Provider business mailing address

3903 SOUTH COBB DR SUITE 105
SMYRNA GA
30080
US

V. Phone/Fax

Practice location:
  • Phone: 678-838-6600
  • Fax: 770-438-1477
Mailing address:
  • Phone: 678-838-6600
  • Fax: 770-438-1477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberGA052966
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberGA052966
License Number StateGA

VIII. Authorized Official

Name: MIGUEL A JIMENEZ
Title or Position: PRESIDENT
Credential: MD
Phone: 678-838-6600