Healthcare Provider Details

I. General information

NPI: 1386810786
Provider Name (Legal Business Name): GWINNETT MEDICAL BACK AND NECK PAIN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2008
Last Update Date: 08/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5860 JIMMY CARTER BLVD SUITE 110
NORCROSS GA
30071-4662
US

IV. Provider business mailing address

5860 JIMMY CARTER BLVD SUITE 110
NORCROSS GA
30071-4662
US

V. Phone/Fax

Practice location:
  • Phone: 770-263-2063
  • Fax: 770-407-8546
Mailing address:
  • Phone: 770-263-2063
  • Fax: 770-407-8546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL COHEN
Title or Position: MANAGER
Credential: D.C.
Phone: 770-263-2063