Provider Demographics
NPI:1679857106
Name:PREMIER ORTHOSPORTS, INC.
Entity Type:Organization
Organization Name:PREMIER ORTHOSPORTS, INC.
Other - Org Name:ORTHOSPORTS ATHENS, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:256-233-2332
Mailing Address - Street 1:1860 US HIGHWAY 43
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:AL
Mailing Address - Zip Code:35594-5062
Mailing Address - Country:US
Mailing Address - Phone:202-487-1111
Mailing Address - Fax:205-487-1114
Practice Address - Street 1:15243 GREENFIELD DR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35613-2899
Practice Address - Country:US
Practice Address - Phone:256-233-2332
Practice Address - Fax:256-216-3579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO1220207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty