Provider Demographics
NPI:1558800979
Name:OPTIM ORTHOPEDICS LLC
Entity Type:Organization
Organization Name:OPTIM ORTHOPEDICS LLC
Other - Org Name:OPTIM ORTHOPEDICS MEMORIAL JESUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-644-5300
Mailing Address - Street 1:166 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31545-0101
Mailing Address - Country:US
Mailing Address - Phone:912-644-5300
Mailing Address - Fax:912-644-5260
Practice Address - Street 1:210 E DERENNE AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6736
Practice Address - Country:US
Practice Address - Phone:912-644-5300
Practice Address - Fax:912-644-5260
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OPTIM ORTHOPEDICS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-17
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty