Basic Information
| Provider Information | |||||||||
| NPI: | 1518096122 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DOMINION ORTHOPAEDIC CLINIC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5555 PEACHTREE DUNWOODY RD NE | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704554009 | ||||||||
| FaxNumber: | 7704554065 | ||||||||
| Practice Location | |||||||||
| Address1: | 5555 PEACHTREE DUNWOODY RD NE | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704554009 | ||||||||
| FaxNumber: | 7704554065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2007 | ||||||||
| LastUpdateDate: | 09/11/2009 | ||||||||
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| AuthorizedOfficialLastName: | FOSTER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7704554009 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 174400000X | 037539 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.