Basic Information
| Provider Information | |||||||||
| NPI: | 1013459551 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EFFINGHAM ORTHOPEDIC PRACTICE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | EFFINGHAM ORTHOPAEDIC CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 459 HIGHWAY 119 S | ||||||||
| Address2: | ATTN.: ALIA ALLEN - MEDICAL STAFF OFFICE | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313293021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127540175 | ||||||||
| FaxNumber: | 9127546395 | ||||||||
| Practice Location | |||||||||
| Address1: | 613 TOWNE PARK DR W | ||||||||
| Address2: | SUITE 303-304 | ||||||||
| City: | RINCON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313265182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9128263111 | ||||||||
| FaxNumber: | 9128263120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2016 | ||||||||
| LastUpdateDate: | 07/01/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BAKER-WITT | ||||||||
| AuthorizedOfficialFirstName: | FRANCINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CEO | ||||||||
| AuthorizedOfficialTelephone: | 9127540142 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN,MBA,CHNA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.