Basic Information
| Provider Information | |||||||||
| NPI: | 1639293988 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNTAINSIDE ORTHOPEDICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 102321 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303682321 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 620 J L WHITE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | JASPER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301434896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066926980 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 01/08/2009 | ||||||||
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| AuthorizedOfficialLastName: | TARDIF | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7708012526 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 035504 | GA | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.