Provider Demographics
NPI:1477586063
Name:ATHENS ORTHOPEDIC CLINIC AMBULATORY SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:ATHENS ORTHOPEDIC CLINIC AMBULATORY SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KARL
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-549-1663
Mailing Address - Street 1:1765 OLD WEST BROAD ST
Mailing Address - Street 2:BLDG 1, STE 300
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2853
Mailing Address - Country:US
Mailing Address - Phone:706-549-1663
Mailing Address - Fax:706-546-8792
Practice Address - Street 1:1765 OLD WEST BROAD ST
Practice Address - Street 2:BLDG 1, STE 300
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2853
Practice Address - Country:US
Practice Address - Phone:706-549-1663
Practice Address - Fax:706-546-8792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA111286ASCAMedicare PIN