=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649204751
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIGUEL A JIMENEZ M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2006
-----------------------------------------------------
Last Update Date | 10/31/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3903 S COBB DR SE SUITE 105
-----------------------------------------------------
City | SMYRNA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30080-6342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-838-6600
-----------------------------------------------------
Fax | 770-438-1477
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3280 POINTE PKWY STE 2550
-----------------------------------------------------
City | NORCROSS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30092-3473
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-877-7411
-----------------------------------------------------
Fax | 877-877-7411
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XS0117X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery of the Spine Physician
-----------------------------------------------------
License Number | 52966
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------