Provider Demographics
NPI:1871553297
Name:SPINE & ORTHOPEDIC CENTER
Entity type:Organization
Organization Name:SPINE & ORTHOPEDIC CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PRAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:SOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-473-0038
Mailing Address - Street 1:1287 HWY 138
Mailing Address - Street 2:SPUR #8
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236
Mailing Address - Country:US
Mailing Address - Phone:770-473-0038
Mailing Address - Fax:770-471-4290
Practice Address - Street 1:1287 HWY 138
Practice Address - Street 2:SPUR #8
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236
Practice Address - Country:US
Practice Address - Phone:770-473-0038
Practice Address - Fax:770-471-4290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021593207XX0801X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic TraumaGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA157600900OtherDEPT OF LABOR
GA303578OtherWELLCARE
GA495745OtherBLUE CROSS BLUE SHIELD
GAP0908912OtherUNITED HEALTHCARE
GA000200934CMedicaid
GA200020230OtherRAILROAD MEDICARE
GA0954880002Medicare NSC
GA495745OtherBLUE CROSS BLUE SHIELD