Provider Demographics
NPI:1710071931
Name:GWINNETT SPORTS MEDICINE & ORTHOPAEDIC SURGERY PC
Entity Type:Organization
Organization Name:GWINNETT SPORTS MEDICINE & ORTHOPAEDIC SURGERY PC
Other - Org Name:ATLANTA CENTER FOR ATHLETES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:WOESTMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-622-4499
Mailing Address - Street 1:10680 MEDLOCK BRIDGE ROAD
Mailing Address - Street 2:STE 102
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097
Mailing Address - Country:US
Mailing Address - Phone:770-622-4499
Mailing Address - Fax:770-622-0315
Practice Address - Street 1:10680 MEDLOCK BRIDGE ROAD
Practice Address - Street 2:STE 102
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097
Practice Address - Country:US
Practice Address - Phone:770-622-4499
Practice Address - Fax:770-622-0315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP934Medicare PIN