Provider Demographics
NPI:1760684609
Name:GEORGIA SPINE & NEUROSURGERY CENTER LLC
Entity Type:Organization
Organization Name:GEORGIA SPINE & NEUROSURGERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAVEH
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAJAVI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-299-3338
Mailing Address - Street 1:2675 N DECATUR RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6131
Mailing Address - Country:US
Mailing Address - Phone:404-299-3338
Mailing Address - Fax:404-299-3315
Practice Address - Street 1:2675 N DECATUR RD
Practice Address - Street 2:SUITE 110
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6131
Practice Address - Country:US
Practice Address - Phone:404-299-3338
Practice Address - Fax:404-299-3315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA51201207T00000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1487610275OtherKHAJAVI NPI
1306807094OtherGULLICK NPI
1093771891OtherMIHELIC NPI
1972627396OtherDME NPI
GA00944358BMedicaid
GA931766736AMedicaid
1093771891OtherMIHELIC NPI
H29606Medicare UPIN
GA00944358BMedicaid
4918650001Medicare NSC
1487610275OtherKHAJAVI NPI