Provider Demographics
NPI:1639368459
Name:SOUTH ATL ORTHO & SPTS
Entity Type:Organization
Organization Name:SOUTH ATL ORTHO & SPTS
Other - Org Name:ALEXANDER N. DOMAN, MD
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:DOMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-362-9935
Mailing Address - Street 1:425 FOREST PKWY
Mailing Address - Street 2:SUITE111
Mailing Address - City:FOREST PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30297-2185
Mailing Address - Country:US
Mailing Address - Phone:404-362-9935
Mailing Address - Fax:404-362-9938
Practice Address - Street 1:425 FOREST PARKWAY
Practice Address - Street 2:SUITE 111
Practice Address - City:FOREST PARK
Practice Address - State:GA
Practice Address - Zip Code:30297-2342
Practice Address - Country:US
Practice Address - Phone:404-362-9935
Practice Address - Fax:404-362-9938
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH ATLANTA ORTHOPEDICS & SPORTS MEDICINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-17
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033313261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000444881AMedicaid
GA000444881AMedicaid