=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992479596
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. MARY SPINE AND SPORT INJURIES REHAB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2021
-----------------------------------------------------
Last Update Date | 05/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 502 E US HIGHWAY 80 STE D
-----------------------------------------------------
City | BLOOMINGDALE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31302-9356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-999-7275
-----------------------------------------------------
Fax | 912-988-3748
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 502 E US HIGHWAY 80 STE D
-----------------------------------------------------
City | BLOOMINGDALE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31302-9356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER/OWNER
-----------------------------------------------------
Name | NOHA RAOUF SOLIMAN
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 912-508-8828
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------