Provider Demographics
NPI:1851602429
Name:NORTH GEORGIA SPINE AND INTERVENTIONAL ORTHOPEDICS LLC
Entity Type:Organization
Organization Name:NORTH GEORGIA SPINE AND INTERVENTIONAL ORTHOPEDICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SALLU
Authorized Official - Middle Name:
Authorized Official - Last Name:JABATI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-559-4526
Mailing Address - Street 1:1897 HIGHWAY 211 NW STE 105
Mailing Address - Street 2:
Mailing Address - City:HOSCHTON
Mailing Address - State:GA
Mailing Address - Zip Code:30548-3514
Mailing Address - Country:US
Mailing Address - Phone:706-253-3341
Mailing Address - Fax:770-307-0306
Practice Address - Street 1:1897 HIGHWAY 211 NW STE 105
Practice Address - Street 2:
Practice Address - City:HOSCHTON
Practice Address - State:GA
Practice Address - Zip Code:30548-3514
Practice Address - Country:US
Practice Address - Phone:706-253-3341
Practice Address - Fax:770-307-0306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-29
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058527208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA712681970BMedicaid
1235104431OtherNPI INDIVIDUAL