Basic Information
| Provider Information | |||||||||
| NPI: | 1609109719 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATHENS MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | ATHENS ORTHOPEDICS AND SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1660 LAFAYETTE RD | ||||||||
| Address2: | |||||||||
| City: | CRAWFORDSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479334601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7653645360 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1702 LAFAYETTE RD | ||||||||
| Address2: | |||||||||
| City: | CRAWFORDSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479331033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7653624400 | ||||||||
| FaxNumber: | 7653641797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2009 | ||||||||
| LastUpdateDate: | 09/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | TERRENCE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7654236161 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.