Basic Information
| Provider Information | |||||||||
| NPI: | 1659715803 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORTHOSPORTS ATHENS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1860 US HIGHWAY 43 | ||||||||
| Address2: | |||||||||
| City: | WINFIELD | ||||||||
| State: | AL | ||||||||
| PostalCode: | 355945062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054871111 | ||||||||
| FaxNumber: | 2054871114 | ||||||||
| Practice Location | |||||||||
| Address1: | 42030 HIGHWAY 195 | ||||||||
| Address2: | SUITE A | ||||||||
| City: | HALEYVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 355657054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054857248 | ||||||||
| FaxNumber: | 2054857249 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2013 | ||||||||
| LastUpdateDate: | 04/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | BOYETT | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | PATRICK | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2562332332 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.