Provider Demographics
NPI:1578783080
Name:UPSON ORTHOPAEDIC CLINIC
Entity Type:Organization
Organization Name:UPSON ORTHOPAEDIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:RUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-646-4371
Mailing Address - Street 1:612 W GORDON ST
Mailing Address - Street 2:STE A
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-3416
Mailing Address - Country:US
Mailing Address - Phone:706-646-4371
Mailing Address - Fax:706-646-4373
Practice Address - Street 1:612 W GORDON ST
Practice Address - Street 2:STE A
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-3416
Practice Address - Country:US
Practice Address - Phone:706-646-4371
Practice Address - Fax:706-646-4373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041777174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1295280001Medicare NSC
GAA98948Medicare UPIN