Provider Demographics
NPI:1326120866
Name:POLARIS SPINE & NEUROSURGERY CENTER PC
Entity Type:Organization
Organization Name:POLARIS SPINE & NEUROSURGERY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HERR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-957-3025
Mailing Address - Street 1:1150 HAMMOND DR. BLDG E SUITE 400
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328
Mailing Address - Country:US
Mailing Address - Phone:404-234-2753
Mailing Address - Fax:404-255-6532
Practice Address - Street 1:1150 HAMMOND DR. BLDG E SUITE 400
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328
Practice Address - Country:US
Practice Address - Phone:404-234-2753
Practice Address - Fax:404-255-6532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA055001482AMedicaid
GAGRP1585Medicare ID - Type Unspecified