Provider Demographics
NPI:1841736303
Name:GWINNETT SPINE SPECIALISTS LLC
Entity Type:Organization
Organization Name:GWINNETT SPINE SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:S
Authorized Official - Last Name:PIRTLE
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:770-755-9137
Mailing Address - Street 1:1625 PLEASANT HILL RD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-2326
Mailing Address - Country:US
Mailing Address - Phone:470-299-6859
Mailing Address - Fax:470-299-8397
Practice Address - Street 1:1625 PLEASANT HILL RD
Practice Address - Street 2:SUITE 215
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-2326
Practice Address - Country:US
Practice Address - Phone:470-299-6859
Practice Address - Fax:470-299-8397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO08008111N00000X
GA1831215714208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1043336498OtherNPI NUMBER
GA202I013104OtherMEDCARE PTAN NUMBER