Basic Information
| Provider Information | |||||||||
| NPI: | 1710946322 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIANS SPINE AND REHAB SPECIALISTS OF GA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 CHURCH ST NE | ||||||||
| Address2: | SUITE 550 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300607282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704199902 | ||||||||
| FaxNumber: | 7704197457 | ||||||||
| Practice Location | |||||||||
| Address1: | 5730 GLENRIDGE DR NE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SANDY SPRINGS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303286141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048163000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 03/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | RAZIANO | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
| AuthorizedOfficialMiddleName: | CASSIDY | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER / OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4048163000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PHYSICIANS SPINE & REHABILITATION SPECIALISTS OF GEORGIA P.C. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 03/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 050988 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.