Healthcare Provider Details

I. General information

NPI: 1467904433
Provider Name (Legal Business Name): ORTHO SPORT & SPINE PHYSICIANS MACON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 ARKWRIGHT RD
MACON GA
31210-1303
US

IV. Provider business mailing address

3200 RIVERSIDE DR SUITE 200
MACON GA
31210-2550
US

V. Phone/Fax

Practice location:
  • Phone: 678-752-7246
  • Fax:
Mailing address:
  • Phone: 404-935-9116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JANESSA HASTINGS
Title or Position: DIR. OF REVEUNE MANAGEMENT
Credential:
Phone: 404-935-9116