Provider Demographics
NPI:1104017821
Name:MARK SPIVEY ORTHOPEDIC CLINIC, LLC
Entity Type:Organization
Organization Name:MARK SPIVEY ORTHOPEDIC CLINIC, LLC
Other - Org Name:MARK SPIVEY ORTHOPEDIC CLINIC, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:M
Authorized Official - Last Name:SPIVEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-537-4411
Mailing Address - Street 1:3301 E 1ST ST
Mailing Address - Street 2:STE A
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8674
Mailing Address - Country:US
Mailing Address - Phone:912-537-4411
Mailing Address - Fax:912-538-8485
Practice Address - Street 1:3301 E 1ST ST
Practice Address - Street 2:STE A
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8674
Practice Address - Country:US
Practice Address - Phone:912-537-4411
Practice Address - Fax:912-538-8485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047846207X00000X
GA207X00000X
207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA501468518EMedicaid
GA6205610001Medicare NSC
GA501468518EMedicaid