1598719643 NPI number — COLISEUM MEDICAL CENTER, LLC

Table of content: (NPI 1598719643)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598719643 NPI number — COLISEUM MEDICAL CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLISEUM MEDICAL CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PIEDMONT MACON MEDICAL CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598719643
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 HOSPITAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31217-3838
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-765-7000
Provider Business Mailing Address Fax Number:
478-742-1247

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
C/O COLISEUM HEALTH SYSTEM
Provider Second Line Business Practice Location Address:
350 HOSPITAL DRIVE
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-765-7000
Provider Business Practice Location Address Fax Number:
478-742-1247
Provider Enumeration Date:
05/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CROSS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
C
Authorized Official Title or Position:
VP GOVERNMENT REIMBURSEMENT
Authorized Official Telephone Number:
470-271-3401

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00000459A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3522 . This is a "BLUE CROSS" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 25706 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 912181100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4103009 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 166202500 . This is a "DEPT OF LABOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200461450A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: HOS0164N , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1729302 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 203375 . This is a "FLORIDA MEDICAID HMO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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