Provider Demographics
NPI:1013206952
Name:GEORGIA SPINE SPECIALISTS
Entity Type:Organization
Organization Name:GEORGIA SPINE SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-374-3714
Mailing Address - Street 1:11 MAYBELLE ST
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-3615
Mailing Address - Country:US
Mailing Address - Phone:770-334-2065
Mailing Address - Fax:770-334-2066
Practice Address - Street 1:3903 S COBB DR SE
Practice Address - Street 2:STE 105
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-8504
Practice Address - Country:US
Practice Address - Phone:678-838-6600
Practice Address - Fax:770-438-1477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA52966174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7885OtherMEDICARE GROUP NUMBER