Provider Demographics
NPI:1386819217
Name:MYERS SPORTS MEDICINE AND ORTHOPAEDIC CENTER
Entity Type:Organization
Organization Name:MYERS SPORTS MEDICINE AND ORTHOPAEDIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:REGILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:FISH
Authorized Official - Suffix:
Authorized Official - Credentials:ATC/L
Authorized Official - Phone:404-352-8156
Mailing Address - Street 1:3200 DOWNWOOD CIR NW STE 340
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-1605
Mailing Address - Country:US
Mailing Address - Phone:404-352-8156
Mailing Address - Fax:404-350-9405
Practice Address - Street 1:3200 DOWNWOOD CIR NW STE 340
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-1605
Practice Address - Country:US
Practice Address - Phone:404-352-8156
Practice Address - Fax:404-350-9405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA6201260001Medicare NSC