Provider Demographics
NPI:1417178633
Name:GEORGIA TECH SPORTS MEDICINE AND REHAB
Entity Type:Organization
Organization Name:GEORGIA TECH SPORTS MEDICINE AND REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST CLINIC DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RIDGEWAY
Authorized Official - Suffix:
Authorized Official - Credentials:BS, PT
Authorized Official - Phone:404-385-4115
Mailing Address - Street 1:150 BOBBY DODD WAY
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30332-0001
Mailing Address - Country:US
Mailing Address - Phone:404-385-4115
Mailing Address - Fax:404-894-0695
Practice Address - Street 1:150 BOBBY DODD WAY
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30332-0001
Practice Address - Country:US
Practice Address - Phone:404-385-4115
Practice Address - Fax:404-894-0695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6601225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty