Provider Demographics
NPI:1750422432
Name:PEACHSTATE ORTHOPEDICS P C
Entity type:Organization
Organization Name:PEACHSTATE ORTHOPEDICS P C
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:MERRITT
Authorized Official - Last Name:WANDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-631-6410
Mailing Address - Street 1:211 PRIME PT
Mailing Address - Street 2:SUITE 2H
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-3334
Mailing Address - Country:US
Mailing Address - Phone:770-631-6410
Mailing Address - Fax:770-631-6413
Practice Address - Street 1:211 PRIME PT
Practice Address - Street 2:SUITE 2H
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-3334
Practice Address - Country:US
Practice Address - Phone:770-631-6410
Practice Address - Fax:770-631-6413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAE51682Medicare UPIN
GA0923680001Medicare NSC