Provider Demographics
NPI:1720023500
Name:CENTER FOR RECONSTRUCTIVE SURGERY
Entity Type:Organization
Organization Name:CENTER FOR RECONSTRUCTIVE SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:ALVAREZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:770-487-6716
Mailing Address - Street 1:7130 MOUNT ZION BLVD
Mailing Address - Street 2:SUITE 14
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-2518
Mailing Address - Country:US
Mailing Address - Phone:770-716-8732
Mailing Address - Fax:770-716-1330
Practice Address - Street 1:7130 MOUNT ZION BLVD
Practice Address - Street 2:SUITE 14
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-2518
Practice Address - Country:US
Practice Address - Phone:770-716-8732
Practice Address - Fax:770-716-1330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060-083261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA111057ASCAMedicare PIN