Healthcare Provider Details

I. General information

NPI: 1831270586
Provider Name (Legal Business Name): MOUNTAINSIDE ORTHOPEDICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 J L WHITE DR STE 100
JASPER GA
30143-4897
US

IV. Provider business mailing address

620 J L WHITE DR STE 100
JASPER GA
30143-4897
US

V. Phone/Fax

Practice location:
  • Phone: 706-692-6980
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number035504
License Number StateGA

VIII. Authorized Official

Name: JENNIFER TARDIF
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 770-801-2526