MEDICARE: MARK SPIVEY ORTHOPEDIC CLINIC, LLC

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	207X00000X	Orthopaedic Surgery Physician		GA
2	207X00000X	Orthopaedic Surgery Physician	047846	GA
3	207X00000X	Orthopaedic Surgery Physician

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

General Provider Information

NPI Number	:	1104017821
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK SPIVEY ORTHOPEDIC CLINIC, LLC

Provider Business Mailing Address
First Line	:	3301 E 1ST ST STE A
Second Line	:
City	:	VIDALIA
State	:	GA
Zip	:	30474-8674
Country	:	US
Telephone Number	:	912-537-4411
Fax Number	:	912-538-8485

Provider Business Practice Location Address
First Line	:	3301 E 1ST ST
Second Line	:	STE A
City	:	VIDALIA
State	:	GA
Zip	:	30474-8674
Country	:	US
Telephone Number	:	912-537-4411
Fax Number	:	912-538-8485

Authorized Official
Title or Position	:	OWNER
Name	:	CHARLES M SPIVEY
Credential	:	MD
Telephone Number	:	912-537-4411

Provider Enumeration Date	:	08/07/2007
Last Update Date	:	06/04/2026

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