Provider Demographics
NPI:1003135336
Name:HAYNES SPORTS MEDICINE
Entity Type:Organization
Organization Name:HAYNES SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:BRYCE
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:678-513-8111
Mailing Address - Street 1:2065 SOUTHERS CIR
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-5487
Mailing Address - Country:US
Mailing Address - Phone:678-513-8111
Mailing Address - Fax:678-990-1956
Practice Address - Street 1:6335 HOSPITAL PKWY STE 302
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-5712
Practice Address - Country:US
Practice Address - Phone:678-513-8111
Practice Address - Fax:678-990-1956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-26
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E39212Medicare UPIN