Healthcare Provider Details

I. General information

NPI: 1376602565
Provider Name (Legal Business Name): PREMIER ORTHOPAEDIC SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 08/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7360 MCGINNIS FERRY RD SUITE E
SUWANEE GA
30024-6603
US

IV. Provider business mailing address

7360 MCGINNIS FERRY RD SUITE E
SUWANEE GA
30024-6603
US

V. Phone/Fax

Practice location:
  • Phone: 678-513-8111
  • Fax: 678-990-1956
Mailing address:
  • Phone: 678-513-8111
  • Fax: 678-990-1956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: WANDA HAYES
Title or Position: OFFICE MANAGER
Credential:
Phone: 678-513-8111