Provider Demographics
NPI:1407024623
Name:GEORGIA SPORTS ORTHOPEDIC SPECIALISTS, L.L.C
Entity Type:Organization
Organization Name:GEORGIA SPORTS ORTHOPEDIC SPECIALISTS, L.L.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:R
Authorized Official - Last Name:NOON
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:770-532-0503
Mailing Address - Street 1:1466 JESSE JEWELL PKWY SE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3852
Mailing Address - Country:US
Mailing Address - Phone:770-532-0503
Mailing Address - Fax:770-534-6942
Practice Address - Street 1:1466 JESSE JEWELL PKWY SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3852
Practice Address - Country:US
Practice Address - Phone:770-532-0503
Practice Address - Fax:770-534-6942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4563Medicare PIN