Basic Information
Provider Information | |||||||||
NPI: | 1265053110 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SPORTS MEDICINE SOUTH OF GWINNETT LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1001 SUMMIT BLVD STE 1000 | ||||||||
Address2: |   | ||||||||
City: | BROOKHAVEN | ||||||||
State: | GA | ||||||||
PostalCode: | 303196415 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4048518000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1900 RIVERSIDE PKWY | ||||||||
Address2: |   | ||||||||
City: | LAWRENCEVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 300435925 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7702373475 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/01/2020 | ||||||||
LastUpdateDate: | 08/12/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HERNANDEZ | ||||||||
AuthorizedOfficialFirstName: | JORGE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP/CCO | ||||||||
AuthorizedOfficialTelephone: | 4048518000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/12/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No ID Information.