Provider Demographics
NPI:1891229068
Name:ACADEMY ORTHOPEDICS, LLC
Entity Type:Organization
Organization Name:ACADEMY ORTHOPEDICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:NUGENT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-889-0891
Mailing Address - Street 1:3929 CARTER RD
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-1628
Mailing Address - Country:US
Mailing Address - Phone:770-271-9855
Mailing Address - Fax:770-271-1118
Practice Address - Street 1:3929 CARTER RD
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-1628
Practice Address - Country:US
Practice Address - Phone:770-271-9855
Practice Address - Fax:770-271-1118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-14
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA28421207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300025973DMedicaid
GA300025973DMedicaid