Basic Information
| Provider Information | |||||||||
| NPI: | 1063953149 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EFFINGHAM ORTHOPEDIC PRACTICE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EFFINGHAM CHATHAM SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 459 HIGHWAY 119 S | ||||||||
| Address2: | |||||||||
| 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: | 9123556615 | ||||||||
| FaxNumber: | 9123510645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2017 | ||||||||
| LastUpdateDate: | 03/09/2017 | ||||||||
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| AuthorizedOfficialLastName: | BAKER-WITT | ||||||||
| AuthorizedOfficialFirstName: | FRANCINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO & NURSING HOME ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9127540142 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EFFINGHAM ORTHOPEDIC PRACTICE LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.