Basic Information
| Provider Information | |||||||||
| NPI: | 1316977283 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPINE & SACROILIAC SPECIALISTS, LLC | ||||||||
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| Address1: | 3025 BRECKINRIDGE BLVD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | DULUTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300967611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782260082 | ||||||||
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| Practice Location | |||||||||
| Address1: | 550 PEACHTREE ST NE | ||||||||
| Address2: | #1770 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303082247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4045775459 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 12/05/2007 | ||||||||
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| AuthorizedOfficialLastName: | AMARAL | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4045775459 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 053079 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.