Provider Demographics
NPI:1932236684
Name:BUCKHEAD SPORTS MEDICINE AND SPINE CENTER
Entity Type:Organization
Organization Name:BUCKHEAD SPORTS MEDICINE AND SPINE CENTER
Other - Org Name:MIDTOWN SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:FURIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-522-5828
Mailing Address - Street 1:285 BOULEVARD NE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-4205
Mailing Address - Country:US
Mailing Address - Phone:404-522-5828
Mailing Address - Fax:404-222-2322
Practice Address - Street 1:285 BOULEVARD NE STE 310
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-4209
Practice Address - Country:US
Practice Address - Phone:404-522-5828
Practice Address - Fax:404-222-2322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043942174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000938781AMedicaid
GAGRP4609Medicare PIN
GAG2772Medicare UPIN
GA6263010001Medicare NSC