MEDICARE: PEACHSTATE PROSTHETICS AND ORTHOTICS, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	20010497912	OTHER	GA	STATE SALES TAX ID
3	1003810748	OTHER	GA	NPI
4	LPO#000004	OTHER	GA	COMPOSITE MEDICAL BOARD

General Provider Information

NPI Number	:	1003810748
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEACHSTATE PROSTHETICS AND ORTHOTICS, INC

Provider Business Mailing Address
First Line	:	178 BRACKETTS WAY STE 3
Second Line	:
City	:	BLAIRSVILLE
State	:	GA
Zip	:	30512-2984
Country	:	US
Telephone Number	:	706-400-5750
Fax Number	:	706-400-5751

Provider Business Practice Location Address
First Line	:	178 BRACKETTS WAY STE 3
Second Line	:
City	:	BLAIRSVILLE
State	:	GA
Zip	:	30512-2984
Country	:	US
Telephone Number	:	706-400-5750
Fax Number	:	706-400-5751

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SUSAN G SEMMES
Credential	:	LCPO
Telephone Number	:	706-400-5750

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	09/23/2019

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Directions to “PEACHSTATE PROSTHETICS AND ORTHOTICS, INC ” Practice Location

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