Provider Demographics
NPI:1942370408
Name:SOUTHERN BONE & JOINT AMBULATORY SURGICAL CENTER, LLC
Entity Type:Organization
Organization Name:SOUTHERN BONE & JOINT AMBULATORY SURGICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER AND AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BOYD
Authorized Official - Last Name:BALDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-234-5954
Mailing Address - Street 1:1755 HIGHWAY 34 E STE 1100
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-3184
Mailing Address - Country:US
Mailing Address - Phone:707-252-7510
Mailing Address - Fax:404-252-2780
Practice Address - Street 1:5673 PEACHTREE DUNWOODY RD STE 800
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1776
Practice Address - Country:US
Practice Address - Phone:404-255-5595
Practice Address - Fax:404-252-2780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA582430839OtherTAX ID