Basic Information
| Provider Information | |||||||||
| NPI: | 1811912611 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEACHTREE ORTHOPAEDIC CLINIC PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13594 | ||||||||
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| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043550743 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2001 PEACHTREE RD | ||||||||
| Address2: | SUITE 705 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043550743 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 11/14/2017 | ||||||||
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| AuthorizedOfficialLastName: | CHIARAVALLOTI | ||||||||
| AuthorizedOfficialFirstName: | SARANYA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REVENUE SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 4043502447 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DIRECTOR OF REVENUE | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207XP3100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery | 207XS0106X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XS0117X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207XX0004X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Foot and Ankle Surgery | 208VP0014X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.