Provider Demographics
NPI:1831185172
Name:FOUR RIVERS ORTHOPEDIC ASSOC PC
Entity type:Organization
Organization Name:FOUR RIVERS ORTHOPEDIC ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-537-1815
Mailing Address - Street 1:500A MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8998
Mailing Address - Country:US
Mailing Address - Phone:912-537-1815
Mailing Address - Fax:912-537-9557
Practice Address - Street 1:500A MAPLE DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8998
Practice Address - Country:US
Practice Address - Phone:912-537-1815
Practice Address - Fax:912-537-9557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA053327207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA205709OtherBCBS
B46727Medicare UPIN
GRP5199Medicare ID - Type Unspecified