Provider Demographics
NPI:1679806889
Name:DOMINION ORTHOPAEDIC CLINIC, LLC
Entity type:Organization
Organization Name:DOMINION ORTHOPAEDIC CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:I
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:770-455-4009
Mailing Address - Street 1:5555 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:SUITE 215
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1703
Mailing Address - Country:US
Mailing Address - Phone:770-455-4009
Mailing Address - Fax:770-455-4065
Practice Address - Street 1:5830 BOND ST
Practice Address - Street 2:SUITE 200
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-0307
Practice Address - Country:US
Practice Address - Phone:770-455-4009
Practice Address - Fax:770-455-4065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7986OtherMEDICARE PTAN