Provider Demographics
NPI:1831670322
Name:PERFORMANCE ORTHOPAEDICS & SPORTS MEDICINE
Entity type:Organization
Organization Name:PERFORMANCE ORTHOPAEDICS & SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-973-2444
Mailing Address - Street 1:1266 W PACES FERRY RD NW STE 286
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-2306
Mailing Address - Country:US
Mailing Address - Phone:404-973-2444
Mailing Address - Fax:404-935-9832
Practice Address - Street 1:755 MOUNT VERNON HWY NE STE 305
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-4274
Practice Address - Country:US
Practice Address - Phone:404-973-2444
Practice Address - Fax:404-935-9832
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-23
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048913207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000867787IMedicaid
GA003113208AMedicaid