Basic Information
| Provider Information | |||||||||
| NPI: | 1710285226 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RESURGENS, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RESURGENS ORTHOPAEDICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 720580 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303582580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048479999 | ||||||||
| FaxNumber: | 4045318466 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 REINHARDT COLLEGE PKWY | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301145257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6785054455 | ||||||||
| FaxNumber: | 6785054446 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2011 | ||||||||
| LastUpdateDate: | 06/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | LUCAS | ||||||||
| AuthorizedOfficialFirstName: | SUE | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PROVIDER RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 4044593722 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0619450034 | 01 | GA | MEDICARE NSC | OTHER |