Basic Information
| Provider Information | |||||||||
| NPI: | 1518374032 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF NORTH GEORGIA | ||||||||
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| OtherOrganizationName: | UNG SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5050 SPRING VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752443995 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005559073 | ||||||||
| FaxNumber: | 9723673452 | ||||||||
| Practice Location | |||||||||
| Address1: | 82 COLLEGE CIRCLE | ||||||||
| Address2: | MEMORIAL HALL | ||||||||
| City: | DAHLONEGA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068673212 | ||||||||
| FaxNumber: | 7068672799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2014 | ||||||||
| LastUpdateDate: | 07/22/2014 | ||||||||
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| AuthorizedOfficialLastName: | DANIEL | ||||||||
| AuthorizedOfficialFirstName: | MATT | ||||||||
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| AuthorizedOfficialTitleorPosition: | HEAD ATHLETIC TRAINER | ||||||||
| AuthorizedOfficialTelephone: | 7068641669 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MED, ATC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.