Provider Demographics
NPI:1396516860
Name:PHOENIX ORTHO INJURY SPINE AND EXTREMITY MEDICAL SERVICES LLC
Entity type:Organization
Organization Name:PHOENIX ORTHO INJURY SPINE AND EXTREMITY MEDICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-451-2129
Mailing Address - Street 1:1805 PARKE PLAZA CIR STE 101
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3646
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1805 PARKE PLAZA CIR STE 101
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3646
Practice Address - Country:US
Practice Address - Phone:919-451-2129
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty