Provider Demographics
NPI:1740560978
Name:MIDWESTERN ADVANCED ORTHOPAEDICS AND SPORTS MEDICINE INC
Entity Type:Organization
Organization Name:MIDWESTERN ADVANCED ORTHOPAEDICS AND SPORTS MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:TOUSSAINT
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:404-296-5005
Mailing Address - Street 1:433 HIGHLAND AVE NE
Mailing Address - Street 2:APT 1407
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-1391
Mailing Address - Country:US
Mailing Address - Phone:404-296-5005
Mailing Address - Fax:404-296-2070
Practice Address - Street 1:2801 N DECATUR RD
Practice Address - Street 2:SUITE 200
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5949
Practice Address - Country:US
Practice Address - Phone:404-296-5005
Practice Address - Fax:404-296-2070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6115363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty