Provider Demographics
NPI:1457772493
Name:ORTHOPEDIC CENTER PC
Entity Type:Organization
Organization Name:ORTHOPEDIC CENTER PC
Other - Org Name:OPTIM ORTHOPEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-692-6926
Mailing Address - Street 1:210 E DERENNE AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-6736
Mailing Address - Country:US
Mailing Address - Phone:912-692-6926
Mailing Address - Fax:
Practice Address - Street 1:125C VICTORY DR
Practice Address - Street 2:
Practice Address - City:SWAINSBORO
Practice Address - State:GA
Practice Address - Zip Code:30401-3234
Practice Address - Country:US
Practice Address - Phone:877-827-6536
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty