Provider Demographics
NPI:1942285168
Name:PEACHTREE SPINE & PAIN PHYSICIANS ASC, LLC
Entity Type:Organization
Organization Name:PEACHTREE SPINE & PAIN PHYSICIANS ASC, LLC
Other - Org Name:OPTIMUM SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:AUYEUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-835-1493
Mailing Address - Street 1:5555 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:SUITE G-99
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1703
Mailing Address - Country:US
Mailing Address - Phone:404-835-1493
Mailing Address - Fax:678-904-8345
Practice Address - Street 1:5555 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE G-99
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1703
Practice Address - Country:US
Practice Address - Phone:404-843-3323
Practice Address - Fax:404-795-0780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-09
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060-305261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA111257ASCAMedicare ID - Type Unspecified