Basic Information
| Provider Information | |||||||||
| NPI: | 1568066256 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MGO SPINE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3051 WATSON BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310938556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789534563 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3051 WATSON BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310938556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789534563 | ||||||||
| FaxNumber: | 4789534564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2020 | ||||||||
| LastUpdateDate: | 11/24/2020 | ||||||||
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| AuthorizedOfficialLastName: | WRIGHT | ||||||||
| AuthorizedOfficialFirstName: | CYNDI | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4789534563 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0117X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine |
No ID Information.