=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205401726
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORCHARD HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2021
-----------------------------------------------------
Last Update Date | 05/26/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 W MCPHERSON AVE
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31639-2131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-638-6726
-----------------------------------------------------
Fax | 229-518-4425
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 W MCPHERSON AVE
-----------------------------------------------------
City | NASHVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31639-2131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-638-6726
-----------------------------------------------------
Fax | 229-518-4425
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JONATHAN WADE
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 229-638-6726
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------