Provider Demographics
NPI:1083789176
Name:PREMIER ORTHOPAEDICS & SPORTS MEDICINE, PLC
Entity Type:Organization
Organization Name:PREMIER ORTHOPAEDICS & SPORTS MEDICINE, PLC
Other - Org Name:HUGHSTON CLINIC ORTHOPAEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENCHWICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-324-6661
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:706-324-6661
Mailing Address - Fax:
Practice Address - Street 1:5651 FRIST BLVD
Practice Address - Street 2:SUITE 515
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-2054
Practice Address - Country:US
Practice Address - Phone:615-889-3501
Practice Address - Fax:615-889-3349
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREMIER ORTHOPAEDICS & SPORTS MEDICINE, PLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-22
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2000X
TN207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0922510006OtherMEDICARE DME
TN3707844Medicare PIN