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General NPI Number Information
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NPI Number | 1528217544
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Entity Type | Organization
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Legal Business Name | PEACHSTATE ORTHOPEDICS
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Dates
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Enumeration Date | 09/15/2008
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Last Update Date | 09/15/2008
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Provider Practice Location Address
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Address Line | 211 PRIME PT SUITE 2H
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City | PEACHTREE CITY
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State | GA
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Zip | 30269-3334
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Country | US
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Telephone | 770-631-6410
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Fax |
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Provider Business Mailing Address
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Address Line | 211 PRIME PT SUITE 2H
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City | PEACHTREE CITY
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State | GA
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Zip | 30269-3334
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Country | US
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Telephone | 770-631-6410
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | STEVEN MERRITT WANDERMAN
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Credential | M.D.
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Telephone | 770-631-6410
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 036312
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License Number State | GA
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