Provider Demographics
NPI:1700075231
Name:CLAYTON ORTHOPEDIC CLINIC
Entity Type:Organization
Organization Name:CLAYTON ORTHOPEDIC CLINIC
Other - Org Name:EAGLE'S LANDING BONE & JOINT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:COLVARD
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:678-289-5040
Mailing Address - Street 1:1050 EAGLES LANDING PKWY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-9018
Mailing Address - Country:US
Mailing Address - Phone:678-289-5040
Mailing Address - Fax:678-289-2040
Practice Address - Street 1:1050 EAGLES LANDING PKWY
Practice Address - Street 2:SUITE 103
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9020
Practice Address - Country:US
Practice Address - Phone:678-289-5040
Practice Address - Fax:678-289-2040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA013727207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00599068AMedicaid
GA000599068AMedicaid
GAD28916Medicare UPIN
GA00599068AMedicaid
GA257685811AMedicare PIN