Basic Information
| Provider Information | |||||||||
| NPI: | 1831270586 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNTAINSIDE ORTHOPEDICS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 620 J L WHITE DR STE 100 | ||||||||
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| City: | JASPER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301434897 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 620 J L WHITE DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301434897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7066926980 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | TARDIF | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7708012526 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 035504 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.