Basic Information
Provider Information | |||||||||
NPI: | 1962809129 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PREMIER ORTHOPAEDICS & SPORTS MEDICINE, PLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HUGHSTON CLINIC ORTHOPAEDICS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 370 | ||||||||
Address2: |   | ||||||||
City: | FORTSON | ||||||||
State: | GA | ||||||||
PostalCode: | 318080370 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7063246661 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 100 PHYSICIANS WAY | ||||||||
Address2: | SUITE 120 | ||||||||
City: | LEBANON | ||||||||
State: | TN | ||||||||
PostalCode: | 370908102 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6157844336 | ||||||||
FaxNumber: | 6157844337 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/03/2014 | ||||||||
LastUpdateDate: | 10/24/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FROMKIN | ||||||||
AuthorizedOfficialFirstName: | AMANDA | ||||||||
AuthorizedOfficialMiddleName: | GRACE | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF CREDENTIALING | ||||||||
AuthorizedOfficialTelephone: | 7064943071 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
ID Information
ID | Type | State | Issuer | Description | 0922510013 | 01 | TN | MEDICARE DME | OTHER |