Provider Demographics
NPI:1609812593
Name:PEACHTREE ORTHOPAEDIC CLINIC, P.A..
Entity Type:Organization
Organization Name:PEACHTREE ORTHOPAEDIC CLINIC, P.A..
Other - Org Name:PEACHTREE ORTHOPAEDIC PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-365-6560
Mailing Address - Street 1:365 PEACHTREE HILLS AVE NE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-4531
Mailing Address - Country:US
Mailing Address - Phone:404-355-8066
Mailing Address - Fax:404-816-4460
Practice Address - Street 1:365 PEACHTREE HILLS AVE NE
Practice Address - Street 2:SUITE 201
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-4531
Practice Address - Country:US
Practice Address - Phone:404-355-8066
Practice Address - Fax:404-816-4460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP1381Medicare PIN
CB4505Medicare PIN