Healthcare Provider Details

I. General information

NPI: 1447648977
Provider Name (Legal Business Name): ORTHO SPORT & SPINE PHYSICIANS MORROW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2015
Last Update Date: 02/22/2021
Certification Date: 02/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6630 EXCHANGE PL
MORROW GA
30260-2310
US

IV. Provider business mailing address

5788 ROSWELL RD
ATLANTA GA
30328-4904
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number63721
License Number StateGA

VIII. Authorized Official

Name: JANESSA A HASTINGS
Title or Position: DIRECTOR OF REVEUNE
Credential:
Phone: 404-935-9116