Provider Demographics
NPI:1659664399
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:PO BOX 105258
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30348-5258
Mailing Address - Country:US
Mailing Address - Phone:404-355-0743
Mailing Address - Fax:
Practice Address - Street 1:2045 PEACHTREE RD NE STE 600
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1414
Practice Address - Country:US
Practice Address - Phone:404-355-8066
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
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
CB4505Medicare PIN
GRP1381Medicare PIN