MEDICARE: GEORGIA BONE & JOINT, 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	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician

General Provider Information

NPI Number	:	1639936529
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGIA BONE & JOINT, LLC

Provider Business Mailing Address
First Line	:	1755 HIGHWAY 34 E STE 2200
Second Line	:
City	:	NEWNAN
State	:	GA
Zip	:	30265-3190
Country	:	US
Telephone Number	:	770-254-7843
Fax Number	:

Provider Business Practice Location Address
First Line	:	1015 LAFAYETTE PKWY STE 210
Second Line	:
City	:	LAGRANGE
State	:	GA
Zip	:	30241-3584
Country	:	US
Telephone Number	:	770-254-7843
Fax Number	:

Authorized Official
Title or Position	:	OFFICER AND AUTHORIZED OFFICIAL
Name	:	JENNIFER BOYD BALDOCK
Credential	:
Telephone Number	:	615-234-5954

Provider Enumeration Date	:	03/06/2024
Last Update Date	:	12/05/2024

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