Basic Information
| Provider Information | |||||||||
| NPI: | 1023217171 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GEORGIA SPORTS MEDICINE AND ORTHOPEDIC CLINIC, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7630 | ||||||||
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| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317937630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293865222 | ||||||||
| FaxNumber: | 2293826191 | ||||||||
| Practice Location | |||||||||
| Address1: | 1610 JOHN ORR DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | TIFTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317943682 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2293865222 | ||||||||
| FaxNumber: | 2293826191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2007 | ||||||||
| LastUpdateDate: | 07/17/2007 | ||||||||
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| AuthorizedOfficialLastName: | DORMINEY | ||||||||
| AuthorizedOfficialFirstName: | DREW | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR/COO | ||||||||
| AuthorizedOfficialTelephone: | 2293871185 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.