Healthcare Provider Details

I. General information

NPI: 1912730102
Provider Name (Legal Business Name): ORTHO SPORT & SPINE PHYSICIANS SANTA FE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2024
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 SAINT MICHAELS DR STE A101
SANTA FE NM
87505-7668
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: 678-752-7246
  • Fax:

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: FAITH A BELTZHOOVER
Title or Position: RCMDIRECTOR
Credential:
Phone: 678-752-7246