Provider Demographics
NPI:1356483747
Name:CARROLLTON ORTHOPAEDIC CLINIC PC
Entity Type:Organization
Organization Name:CARROLLTON ORTHOPAEDIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-834-0873
Mailing Address - Street 1:150 CLINIC AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4401
Mailing Address - Country:US
Mailing Address - Phone:770-834-0873
Mailing Address - Fax:
Practice Address - Street 1:150 CLINIC AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4401
Practice Address - Country:US
Practice Address - Phone:770-834-0873
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048440207RR0500X
GA16340207X00000X
GA055277208100000X
225100000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty