Provider Demographics
NPI:1720452428
Name:BW SPORTS PRACTICE, LLC
Entity Type:Organization
Organization Name:BW SPORTS PRACTICE, LLC
Other - Org Name:BROOKWOOD SPORTS AND ORTHOPEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL CFO, TENET
Authorized Official - Prefix:MR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:O
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-265-5009
Mailing Address - Street 1:PO BOX 742727
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2727
Mailing Address - Country:US
Mailing Address - Phone:205-877-2663
Mailing Address - Fax:205-874-9622
Practice Address - Street 1:13521 OLD HIGHWAY 280
Practice Address - Street 2:STE. 201B
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242-1405
Practice Address - Country:US
Practice Address - Phone:205-877-2663
Practice Address - Fax:205-874-9622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-18
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports MedicineGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
102G709563Medicare PIN