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General NPI Number Information
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NPI Number | 1154546786
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Entity Type | Organization
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Legal Business Name | MIDDLE GA ORTHOPEADIC
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Dates
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Enumeration Date | 04/17/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3051 WATSON BLVD STE 400
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City | WARNER ROBINS
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State | GA
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Zip | 31093-8556
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Country | US
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Telephone | 478-953-7556
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Fax |
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Provider Business Mailing Address
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Address Line | 3370 ROSA CT
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City | MACON
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State | GA
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Zip | 31216-6737
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | FUNCTIONAL CAPACITY EVALUATOR
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Name | BRIAN THARPE
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Credential | COTA, CEAS, CFCE
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Telephone | 478-953-7556
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 000450
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License Number State | GA
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