Basic Information
| Provider Information | |||||||||
| NPI: | 1609812593 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEACHTREE ORTHOPAEDIC CLINIC, P.A.. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PEACHTREE ORTHOPAEDIC PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 365 PEACHTREE HILLS AVE NE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303054531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043558066 | ||||||||
| FaxNumber: | 4048164460 | ||||||||
| Practice Location | |||||||||
| Address1: | 365 PEACHTREE HILLS AVE NE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303054531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043558066 | ||||||||
| FaxNumber: | 4048164460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 03/17/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COOPER | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 2193656560 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.