Provider Demographics
NPI:1528217544
Name:PEACHSTATE ORTHOPEDICS
Entity Type:Organization
Organization Name:PEACHSTATE ORTHOPEDICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:MERRITT
Authorized Official - Last Name:WANDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-631-6410
Mailing Address - Street 1:211 PRIME PT
Mailing Address - Street 2:SUITE 2H
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-3334
Mailing Address - Country:US
Mailing Address - Phone:770-631-6410
Mailing Address - Fax:
Practice Address - Street 1:211 PRIME PT
Practice Address - Street 2:SUITE 2H
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-3334
Practice Address - Country:US
Practice Address - Phone:770-631-6410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-15
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036312174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty