Basic Information
Provider Information | |||||||||
NPI: | 1306038807 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DUBLIN ORTHOPAEDICS & REHABILITATION, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2400 BELLEVUE RD STE 15 | ||||||||
Address2: | PO BOX 368 | ||||||||
City: | DUBLIN | ||||||||
State: | GA | ||||||||
PostalCode: | 310212894 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4782723022 | ||||||||
FaxNumber: | 4782724233 | ||||||||
Practice Location | |||||||||
Address1: | 2400 BELLEVUE RD STE 15 | ||||||||
Address2: |   | ||||||||
City: | DUBLIN | ||||||||
State: | GA | ||||||||
PostalCode: | 310212894 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4782723022 | ||||||||
FaxNumber: | 4782724233 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/17/2007 | ||||||||
LastUpdateDate: | 05/29/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PETERS | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 4782723022 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D.O. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 022866 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   | 174400000X | 036595 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   | 207X00000X | 036595 | GA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 00539569A | 05 | GA |   | MEDICAID | 00249235C | 05 | GA |   | MEDICAID |