Provider Demographics
NPI:1437521291
Name:COLUMBUS SHOULDER SURGERY & SPORTS MEDICINE LLC
Entity Type:Organization
Organization Name:COLUMBUS SHOULDER SURGERY & SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-596-8844
Mailing Address - Street 1:2045 CENTRE STONE CT
Mailing Address - Street 2:STE A
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-4561
Mailing Address - Country:US
Mailing Address - Phone:706-596-8844
Mailing Address - Fax:844-274-2477
Practice Address - Street 1:2045 CENTRE STONE CT
Practice Address - Street 2:STE A
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-4561
Practice Address - Country:US
Practice Address - Phone:706-596-8844
Practice Address - Fax:844-274-2477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-20
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053576207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty