Provider Demographics
NPI:1578152351
Name:ORTHO SPORT AND SPINE PHYSICIANS CONYERS
Entity Type:Organization
Organization Name:ORTHO SPORT AND SPINE PHYSICIANS CONYERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:RA'KESHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROGDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-941-1233
Mailing Address - Street 1:5788 ROSWELL RD
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-4904
Mailing Address - Country:US
Mailing Address - Phone:305-290-2448
Mailing Address - Fax:
Practice Address - Street 1:1292 WELLBROOK CIR NE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-8031
Practice Address - Country:US
Practice Address - Phone:678-831-7669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-15
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty