Provider Demographics
NPI:1881895035
Name:PROVIDENCE ORTHOPEDICS & SPORTS MEDICINE, PC
Entity type:Organization
Organization Name:PROVIDENCE ORTHOPEDICS & SPORTS MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:HARKINS
Authorized Official - Suffix:I
Authorized Official - Credentials:DO
Authorized Official - Phone:770-267-0978
Mailing Address - Street 1:1401 W SPRING ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-1760
Mailing Address - Country:US
Mailing Address - Phone:770-267-0978
Mailing Address - Fax:770-207-7842
Practice Address - Street 1:1401 W SPRING ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-1760
Practice Address - Country:US
Practice Address - Phone:770-267-0978
Practice Address - Fax:770-207-7842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055950207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7244Medicare PIN