Healthcare Provider Details

I. General information

NPI: 1609244524
Provider Name (Legal Business Name): GEORGIA SPINE & ORTHOPEDICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2015
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 HOSPITAL DR STE 210
MACON GA
31217-8026
US

IV. Provider business mailing address

PO BOX 26984
MACON GA
31221-6984
US

V. Phone/Fax

Practice location:
  • Phone: 478-787-6255
  • Fax: 478-812-8700
Mailing address:
  • Phone: 478-719-8895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number59432
License Number StateGA

VIII. Authorized Official

Name: DR. WINSTON R JESHURAN
Title or Position: ORTHOPEDIC SPINE SURGEON
Credential: MD
Phone: 478-787-6255