Provider Demographics
NPI:1457495616
Name:ALLIANCE ORTHOPAEDICS & SPORTS MEDICINE, PC
Entity Type:Organization
Organization Name:ALLIANCE ORTHOPAEDICS & SPORTS MEDICINE, PC
Other - Org Name:PROACTIVE FITNESS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-322-7333
Mailing Address - Street 1:5040 SNAPFINGER WOODS DR
Mailing Address - Street 2:SUITE 206
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30035-4020
Mailing Address - Country:US
Mailing Address - Phone:770-322-7333
Mailing Address - Fax:770-323-1741
Practice Address - Street 1:5040 SNAPFINGER WOODS DR
Practice Address - Street 2:SUITE 206
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-4020
Practice Address - Country:US
Practice Address - Phone:770-322-7333
Practice Address - Fax:770-323-1741
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALLIANCE ORTHOPAEDICS & SPORTS MEDICINE, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-19
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033304207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA6156040001Medicare NSC
GRP4753Medicare ID - Type Unspecified