Provider Demographics
NPI:1710160601
Name:GEORGIA SPORTS MEDICINE, LLC
Entity Type:Organization
Organization Name:GEORGIA SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:CULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-814-2223
Mailing Address - Street 1:6340 SUGARLOAF PKWY
Mailing Address - Street 2:STE 375
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-4333
Mailing Address - Country:US
Mailing Address - Phone:770-814-2223
Mailing Address - Fax:770-814-2232
Practice Address - Street 1:6340 SUGARLOAF PKWY
Practice Address - Street 2:STE 375
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-4333
Practice Address - Country:US
Practice Address - Phone:770-814-2223
Practice Address - Fax:770-814-2232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043191207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP5069OtherMEDICARE GROUP ID
GAGRP5069OtherMEDICARE GROUP ID