Provider Demographics
NPI:1083941322
Name:SPINE SPECIALISTS OF GEORGIA
Entity Type:Organization
Organization Name:SPINE SPECIALISTS OF GEORGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:A
Authorized Official - Last Name:ELINE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:404-296-5005
Mailing Address - Street 1:2536 BODDIE PL
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-7489
Mailing Address - Country:US
Mailing Address - Phone:404-296-5005
Mailing Address - Fax:404-296-5058
Practice Address - Street 1:2801 N DECATUR RD STE 200
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5936
Practice Address - Country:US
Practice Address - Phone:404-296-5005
Practice Address - Fax:404-296-5058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-06
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048622207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA495498433AMedicaid
GA20NCCHZMedicare PIN