MEDICARE: DR. ROBERT O'CONNELL M.D.

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	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	97890	GA

General Provider Information

NPI Number	:	1063832020
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT O'CONNELL M.D.

Provider Business Mailing Address
First Line	:	150 CLINIC AVE STE 101
Second Line	:
City	:	CARROLLTON
State	:	GA
Zip	:	30117-4402
Country	:	US
Telephone Number	:	770-834-0873
Fax Number	:	770-834-6118

Provider Business Practice Location Address
First Line	:	150 CLINIC AVE STE 101
Second Line	:
City	:	CARROLLTON
State	:	GA
Zip	:	30117-4402
Country	:	US
Telephone Number	:	770-834-0873
Fax Number	:	770-834-6118

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2014
Last Update Date	:	11/17/2023

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