MEDICARE: PEACHTREE SPINE & PAIN PHYSICIANS, 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	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	046109	GA

General Provider Information

NPI Number	:	1831407535
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEACHTREE SPINE & PAIN PHYSICIANS, INC

Provider Business Mailing Address
First Line	:	5555 PEACHTREE DUNWOODY RD NE STE 201
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-1711
Country	:	US
Telephone Number	:	404-843-3323
Fax Number	:	404-574-5944

Provider Business Practice Location Address
First Line	:	4705 LAWRENCEVILLE HWY NW STE A
Second Line	:
City	:	LILBURN
State	:	GA
Zip	:	30047-3667
Country	:	US
Telephone Number	:	404-843-3323
Fax Number	:	404-574-5944

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JEFFREY S GROSSMAN
Credential	:	MD
Telephone Number	:	404-843-3323

Provider Enumeration Date	:	09/16/2010
Last Update Date	:	09/16/2010

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