Provider Demographics
NPI:1720439136
Name:ATLANTA SPORTS AND SPINE LLC
Entity Type:Organization
Organization Name:ATLANTA SPORTS AND SPINE LLC
Other - Org Name:SPORTS AND SPINE INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMRISH
Authorized Official - Middle Name:DINUBHAI
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-580-3607
Mailing Address - Street 1:2340 PATRICK HENRY PKWY
Mailing Address - Street 2:150
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-4325
Mailing Address - Country:US
Mailing Address - Phone:678-866-3646
Mailing Address - Fax:678-804-6862
Practice Address - Street 1:2340 PATRICK HENRY PKWY
Practice Address - Street 2:150
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-4325
Practice Address - Country:US
Practice Address - Phone:678-866-3646
Practice Address - Fax:678-804-6862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-27
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA067950204R00000X, 2081P2900X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic MedicineGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA7562360001Medicare NSC