Provider Demographics
NPI:1114417250
Name:SPINE SPECIALISTS OF ATLANTA, LLC
Entity Type:Organization
Organization Name:SPINE SPECIALISTS OF ATLANTA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:PICCIRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-934-4233
Mailing Address - Street 1:1462 MONTREAL RD. SUITE 212
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-6929
Mailing Address - Country:US
Mailing Address - Phone:770-934-4233
Mailing Address - Fax:678-395-4585
Practice Address - Street 1:1462 MONTREAL RD. SUITE 212
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-6929
Practice Address - Country:US
Practice Address - Phone:770-934-4233
Practice Address - Fax:678-395-4585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA79267208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty