Provider Demographics
NPI:1831413962
Name:ORTHOPEDICS SPORTS MEDICINE & SURGERY, LLC
Entity type:Organization
Organization Name:ORTHOPEDICS SPORTS MEDICINE & SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR PHYSICIAN SEVICES
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOPPER
Authorized Official - Suffix:
Authorized Official - Credentials:MED, RRT
Authorized Official - Phone:706-647-3035
Mailing Address - Street 1:PO BOX 589
Mailing Address - Street 2:801 WEST GORDON ST
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-0008
Mailing Address - Country:US
Mailing Address - Phone:706-647-8111
Mailing Address - Fax:706-647-4389
Practice Address - Street 1:612 W GORDON ST
Practice Address - Street 2:SUITE E
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-3480
Practice Address - Country:US
Practice Address - Phone:706-647-3030
Practice Address - Fax:706-647-3033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-18
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003121667BOtherBOYCE MCD BV
GA003122757AMedicaid
GA003121667AOtherBOYCE MCD TH