Healthcare Provider Details

I. General information

NPI: 1720439136
Provider Name (Legal Business Name): ATLANTA SPORTS AND SPINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 05/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2340 PATRICK HENRY PKWY 150
MCDONOUGH GA
30253-4325
US

IV. Provider business mailing address

2340 PATRICK HENRY PKWY 150
MCDONOUGH GA
30253-4325
US

V. Phone/Fax

Practice location:
  • Phone: 678-866-3646
  • Fax: 678-804-6862
Mailing address:
  • Phone: 678-866-3646
  • Fax: 678-804-6862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number067950
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number067950
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code204R00000X
TaxonomyElectrodiagnostic Medicine Physician
License Number067950
License Number StateGA

VIII. Authorized Official

Name: DR. AMRISH DINUBHAI PATEL
Title or Position: CEO/OWNER
Credential: MD
Phone: 706-580-3607