Basic Information
| Provider Information | |||||||||
| NPI: | 1780860924 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPORTS MEDICINE SOUTH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 RIVERSIDE PKWY | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300435925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702373475 | ||||||||
| FaxNumber: | 7702373756 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 RIVERSIDE PKWY | ||||||||
| Address2: | |||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300435925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702373475 | ||||||||
| FaxNumber: | 7702373756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2008 | ||||||||
| LastUpdateDate: | 01/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | LEVENGOOD | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7702373475 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 040138 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No ID Information.