Provider Demographics
NPI:1598767154
Name:NORTHWEST GEORGIA ORTHOPAEDIC SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:NORTHWEST GEORGIA ORTHOPAEDIC SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER / AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENETHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-763-3893
Mailing Address - Street 1:2550 WINDY HILL RD SE
Mailing Address - Street 2:STE 218
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8665
Mailing Address - Country:US
Mailing Address - Phone:770-953-8058
Mailing Address - Fax:770-951-0096
Practice Address - Street 1:2550 WINDY HILL RD SE
Practice Address - Street 2:STE 218
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8665
Practice Address - Country:US
Practice Address - Phone:770-953-8058
Practice Address - Fax:770-951-0096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-12
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033-108261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00724028AMedicaid
GA3309OtherBLUE CROSS
GA5951075OtherAETNA PPO
GA68-00052OtherUNITED HEALTHCARE
GA853971OtherAETNA H/POS
GA490003330OtherRR MEDICARE
GA853971OtherAETNA H/POS