Provider Demographics
NPI:1083165252
Name:GEORGIA COMPLEX SPINE, LLC
Entity Type:Organization
Organization Name:GEORGIA COMPLEX SPINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHOPAEDIC SPINE SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:678-521-7064
Mailing Address - Street 1:4920 ATLANTA HWY
Mailing Address - Street 2:#134
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-2921
Mailing Address - Country:US
Mailing Address - Phone:678-767-2569
Mailing Address - Fax:678-550-9990
Practice Address - Street 1:1368 SOUTHLAKE PLAZA DR
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-1756
Practice Address - Country:US
Practice Address - Phone:678-767-2569
Practice Address - Fax:678-550-9990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA50385207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000911919Medicaid
1013904697OtherNPI
1013904697OtherNPI