Provider Demographics
NPI:1548795719
Name:SPINE CENTER ATLANTA SOUTH, LLC
Entity Type:Organization
Organization Name:SPINE CENTER ATLANTA SOUTH, LLC
Other - Org Name:SPINE CENTER RIVERDALE, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WEIDLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-351-5812
Mailing Address - Street 1:3161 HOWELL MILL RD NW
Mailing Address - Street 2:STE 310
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-2132
Mailing Address - Country:US
Mailing Address - Phone:404-351-5812
Mailing Address - Fax:678-608-3217
Practice Address - Street 1:102 VINCENT AVE.
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5049
Practice Address - Country:US
Practice Address - Phone:678-974-0158
Practice Address - Fax:678-608-3217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-25
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207X00000X, 208VP0000X
GA063309208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty