Basic Information
| Provider Information | |||||||||
| NPI: | 1245686716 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEACHTREE ORTHOAPEDIC CLINIC, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1901 PHOENIX BLVD | ||||||||
| Address2: | STE 200-MOD C | ||||||||
| City: | COLLEGE PARK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303495063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043550743 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1901 PHOENIX BLVD | ||||||||
| Address2: | STE 200-MOD C | ||||||||
| City: | COLLEGE PARK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303495063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043550743 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2016 | ||||||||
| LastUpdateDate: | 05/13/2016 | ||||||||
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| AuthorizedOfficialLastName: | MITCHELL | ||||||||
| AuthorizedOfficialFirstName: | TOLAN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4043550743 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | Y | Suppliers | Pharmacy |
No ID Information.