Healthcare Provider Details

I. General information

NPI: 1013206952
Provider Name (Legal Business Name): GEORGIA SPINE SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2011
Last Update Date: 03/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3903 S COBB DR SE STE 105
SMYRNA GA
30080-8504
US

IV. Provider business mailing address

11 MAYBELLE ST
CARTERSVILLE GA
30120-3615
US

V. Phone/Fax

Practice location:
  • Phone: 678-838-6600
  • Fax: 770-438-1477
Mailing address:
  • Phone: 770-334-2065
  • Fax: 770-334-2066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number52966
License Number StateGA

VIII. Authorized Official

Name: DR. MIGUEL A JIMENEZ
Title or Position: CEO
Credential: MD
Phone: 770-374-3714