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General NPI Number Information
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NPI Number | 1447595806
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Entity Type | Organization
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Legal Business Name | LTHW SURGICAL, LLC
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Dates
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Enumeration Date | 12/11/2012
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Last Update Date | 12/11/2012
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Provider Practice Location Address
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Address Line | 110 EVANS MILL DR SUITE 401
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City | DALLAS
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State | GA
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Zip | 30157-1622
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Country | US
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Telephone | 678-840-2575
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Fax |
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Provider Business Mailing Address
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Address Line | 110 EVANS MILL DR SUITE 401
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City | DALLAS
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State | GA
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Zip | 30157-1622
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Country | US
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Telephone | 678-840-2575
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Fax |
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Authorized Official
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Title or Position | OPERATING MANAGER
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Name | DR. MICHAEL SHOTWELL
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Credential | M.D.
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Telephone | 678-840-2575
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number | 053168
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License Number State | GA
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