Healthcare Provider Details

I. General information

NPI: 1497752745
Provider Name (Legal Business Name): ORTHOPEDIC SOUTH SURGICAL PARTNERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 FOSTER DR STE A
MCDONOUGH GA
30253-5330
US

IV. Provider business mailing address

156 FOSTER DR STE A
MCDONOUGH GA
30253-5330
US

V. Phone/Fax

Practice location:
  • Phone: 678-422-4230
  • Fax:
Mailing address:
  • Phone: 678-422-4230
  • Fax: 678-422-4287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number031-274
License Number StateGA

VIII. Authorized Official

Name: COLLIN LEMAISTRE
Title or Position: OFFICER/AUTHORIZED OFFICIAL
Credential:
Phone: 469-250-3640