Basic Information
| Provider Information | |||||||||
| NPI: | 1679806889 | ||||||||
| 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: | 5830 BOND ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CUMMING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300400307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704554009 | ||||||||
| FaxNumber: | 7704554065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2009 | ||||||||
| LastUpdateDate: | 09/08/2009 | ||||||||
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| AuthorizedOfficialLastName: | FOSTER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7704554009 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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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 | GRP7986 | 01 | GA | MEDICARE PTAN | OTHER |