Provider Demographics
NPI:1841460912
Name:ATLANTA SOUTH PHYSICAL THERAPY, INC
Entity type:Organization
Organization Name:ATLANTA SOUTH PHYSICAL THERAPY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:BAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-238-7217
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:1275 HIGHWAY 54 W
Practice Address - Street 2:SUITE 202
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4544
Practice Address - Country:US
Practice Address - Phone:770-460-8609
Practice Address - Fax:770-460-8611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADD7784OtherRAILROAD MEDICARE GROUP PROVIDER #
GAGRP7336Medicare PIN
GAGRP7336Medicare Oscar/Certification