Provider Demographics
NPI:1710946322
Name:PHYSICIANS SPINE AND REHAB SPECIALISTS OF GA
Entity Type:Organization
Organization Name:PHYSICIANS SPINE AND REHAB SPECIALISTS OF GA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:CASSIDY
Authorized Official - Last Name:RAZIANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-816-3000
Mailing Address - Street 1:790 CHURCH ST NE
Mailing Address - Street 2:SUITE 550
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-7282
Mailing Address - Country:US
Mailing Address - Phone:770-419-9902
Mailing Address - Fax:770-419-7457
Practice Address - Street 1:790 CHURCH ST NE STE 550
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-8958
Practice Address - Country:US
Practice Address - Phone:770-419-9902
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHYSICIANS SPINE & REHABILITATION SPECIALISTS OF GEORGIA P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-22
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050988174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2620Medicare PIN
GACC5445Medicare PIN