Basic Information
Provider Information | |||||||||
NPI: | 1144365750 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | REHABILITATION PHYSICIANS OF GEORGIA, P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | REHABILITATION PHYSICIANS OF GEORGIA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2450 ATLANTA HWY STE 903 | ||||||||
Address2: |   | ||||||||
City: | CUMMING | ||||||||
State: | GA | ||||||||
PostalCode: | 300401252 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4046595909 | ||||||||
FaxNumber: | 7703999449 | ||||||||
Practice Location | |||||||||
Address1: | 2450 ATLANTA HWY STE 903 | ||||||||
Address2: |   | ||||||||
City: | CUMMING | ||||||||
State: | GA | ||||||||
PostalCode: | 300401252 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4046595909 | ||||||||
FaxNumber: | 7703999449 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/21/2007 | ||||||||
LastUpdateDate: | 03/14/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BURKHAMMER | ||||||||
AuthorizedOfficialFirstName: | AJORI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR OF OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 4046595909 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
ID Information
ID | Type | State | Issuer | Description | 30030873B | 05 | GA |   | MEDICAID |