Provider Demographics
NPI: | 1508302472 |
---|---|
Name: | ORTHOATLANTA, LLC |
Entity Type: | Organization |
Organization Name: | ORTHOATLANTA, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MICHAEL |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | OCHAL |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 770-953-6929 |
Mailing Address - Street 1: | 900 CIRCLE 75 PKWY SE |
Mailing Address - Street 2: | SUITE 1700 |
Mailing Address - City: | ATLANTA |
Mailing Address - State: | GA |
Mailing Address - Zip Code: | 30339-3035 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 770-953-6929 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2785 HIGHWAY 54 |
Practice Address - Street 2: | |
Practice Address - City: | PEACHTREE CITY |
Practice Address - State: | GA |
Practice Address - Zip Code: | 30269-1063 |
Practice Address - Country: | US |
Practice Address - Phone: | 770-460-0094 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-01-16 |
Last Update Date: | 2017-09-13 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
GA | 207X00000X, 207XS0106X, 207XS0114X, 207XS0117X, 207XX0004X, 207XX0005X, 2081P2900X, 2251X0800X, 2471M1202X, 363A00000X, 363L00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
No | 207XS0106X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | Group - Multi-Specialty |
No | 207XS0114X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | Group - Multi-Specialty |
No | 207XS0117X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | Group - Multi-Specialty |
No | 207XX0004X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | Group - Multi-Specialty |
No | 207XX0005X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | Group - Multi-Specialty |
No | 2081P2900X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | Group - Multi-Specialty |
No | 2251X0800X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | Group - Multi-Specialty |
No | 2471M1202X | Technologists, Technicians & Other Technical Service Providers | Radiologic Technologist | Magnetic Resonance Imaging | Group - Multi-Specialty |
No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
GA | GRP4696 | Medicare PIN |