Provider Demographics
NPI:1053466615
Name:GEORGIA SPORTS ORTHOPEDIC SPECIALISTS
Entity Type:Organization
Organization Name:GEORGIA SPORTS ORTHOPEDIC SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMA, ADMINISRTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:A
Authorized Official - Last Name:COUCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-532-0503
Mailing Address - Street 1:1466 JESSE JEWELL PKWY SE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3852
Mailing Address - Country:US
Mailing Address - Phone:770-532-0503
Mailing Address - Fax:770-532-2284
Practice Address - Street 1:1466 JESSE JEWELL PKWY SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3852
Practice Address - Country:US
Practice Address - Phone:770-532-0503
Practice Address - Fax:770-532-2284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty