Provider Demographics
NPI:1245579234
Name:ATLAS INTEGRATIVE MEDICINE AND SPINE CENTER LLC
Entity type:Organization
Organization Name:ATLAS INTEGRATIVE MEDICINE AND SPINE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-251-4345
Mailing Address - Street 1:820 EBENEZER CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:SHARPSBURG
Mailing Address - State:GA
Mailing Address - Zip Code:30277-2073
Mailing Address - Country:US
Mailing Address - Phone:770-251-4345
Mailing Address - Fax:770-251-8072
Practice Address - Street 1:820 EBENEZER CHURCH RD
Practice Address - Street 2:
Practice Address - City:SHARPSBURG
Practice Address - State:GA
Practice Address - Zip Code:30277-2073
Practice Address - Country:US
Practice Address - Phone:770-251-4345
Practice Address - Fax:770-251-8072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-11
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA176824363LP2300X
GA332B00000X
GA67600208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G700991Medicare PIN
GA7011550001Medicare NSC