Basic Information
| Provider Information | |||||||||
| NPI: | 1831699958 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGENERATIVE SPORTS MEDICINE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3223 BAGLEY PSGE | ||||||||
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| City: | DULUTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300973790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444694936 | ||||||||
| FaxNumber: | 3368820236 | ||||||||
| Practice Location | |||||||||
| Address1: | 3855 PLEASANT HILL RD | ||||||||
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| City: | DULUTH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300961407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783126800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2018 | ||||||||
| LastUpdateDate: | 03/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | EL-AMIN | ||||||||
| AuthorizedOfficialFirstName: | SAADIQ | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2178163852 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | MD, PHD | ||||||||
| NPICertificationDate: | 03/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.