Healthcare Provider Details

I. General information

NPI: 1831413962
Provider Name (Legal Business Name): ORTHOPEDICS SPORTS MEDICINE & SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2010
Last Update Date: 07/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 W GORDON ST SUITE E
THOMASTON GA
30286-3480
US

IV. Provider business mailing address

PO BOX 589 801 WEST GORDON ST
THOMASTON GA
30286-0008
US

V. Phone/Fax

Practice location:
  • Phone: 706-647-3030
  • Fax: 706-647-3033
Mailing address:
  • Phone: 706-647-8111
  • Fax: 706-647-4389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. CAROL L HOPPER
Title or Position: DIRECTOR PHYSICIAN SEVICES
Credential: M.ED., RRT
Phone: 706-647-3035