Basic Information
| Provider Information | |||||||||
| NPI: | 1558800979 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPTIM ORTHOPEDICS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OPTIM ORTHOPEDICS MEMORIAL JESUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 166 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | JESUP | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315450101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126445300 | ||||||||
| FaxNumber: | 9126445260 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 E DERENNE AVE | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314056736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126445300 | ||||||||
| FaxNumber: | 9126445260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2017 | ||||||||
| LastUpdateDate: | 02/17/2017 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9126445300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OPTIM ORTHOPEDICS LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.