=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043930985
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORTHO SPORT & SPINE GAINESVILLE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2022
-----------------------------------------------------
Last Update Date | 08/31/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1990 LIMESTONE CIR
-----------------------------------------------------
City | GAINESVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30501-7445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-752-7246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5788 ROSWELL RD
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30328-4904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-752-7246
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RCM DIRECTOR
-----------------------------------------------------
Name | FAITH A BELTZHOOVER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-752-7246
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------