Basic Information
| Provider Information | |||||||||
| NPI: | 1679857106 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIER ORTHOSPORTS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ORTHOSPORTS ATHENS, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1860 US HIGHWAY 43 | ||||||||
| Address2: | |||||||||
| City: | WINFIELD | ||||||||
| State: | AL | ||||||||
| PostalCode: | 355945062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024871111 | ||||||||
| FaxNumber: | 2054871114 | ||||||||
| Practice Location | |||||||||
| Address1: | 15243 GREENFIELD DR | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356132899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562332332 | ||||||||
| FaxNumber: | 2562163579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2011 | ||||||||
| LastUpdateDate: | 10/03/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LAWRENCE | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2562332332 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | DO1220 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.