Basic Information
| Provider Information | |||||||||
| NPI: | 1043527708 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEACHTREE SPINE & PAIN PHYSICIANS, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PEACHTREE SPINE PHYSICIANS, INC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5555 PEACHTREE DUNWOODY RD NE STE 201 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048433323 | ||||||||
| FaxNumber: | 4045745944 | ||||||||
| Practice Location | |||||||||
| Address1: | 4255 JOHNS CREEK PKWY STE C | ||||||||
| Address2: | |||||||||
| City: | SUWANEE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300246122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048433323 | ||||||||
| FaxNumber: | 4045745944 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2010 | ||||||||
| LastUpdateDate: | 09/01/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GROSSMAN | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4048433323 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PEACHTREE SPINE & PAIN PHYSICIANS, INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | 046109 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
No ID Information.