=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750422432
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEACHSTATE ORTHOPEDICS P C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2007
-----------------------------------------------------
Last Update Date | 06/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 211 PRIME PT SUITE 2H
-----------------------------------------------------
City | PEACHTREE CITY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30269-3334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-631-6410
-----------------------------------------------------
Fax | 770-631-6413
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 211 PRIME PT SUITE 2H
-----------------------------------------------------
City | PEACHTREE CITY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30269-3334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-631-6410
-----------------------------------------------------
Fax | 770-631-6413
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. STEVEN MERRITT WANDERMAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 770-631-6410
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------