1629018023 NPI number — COLISEUM PRIMARY CARE SERVICES, LLC

Table of content: (NPI 1629018023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629018023 NPI number — COLISEUM PRIMARY CARE SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLISEUM PRIMARY CARE SERVICES, 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:
Provider Other Organization Name Type Code:
6
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:
1629018023
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 403570
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30384-3570
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-474-4343
Provider Business Mailing Address Fax Number:
844-664-2283

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
380 HOSPITAL DR
Provider Second Line Business Practice Location Address:
BLDG A SUITE 370
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31217-8001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-474-4343
Provider Business Practice Location Address Fax Number:
844-664-2283
Provider Enumeration Date:
06/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TURNER
Authorized Official First Name:
KRISTINE
Authorized Official Middle Name:
Authorized Official Title or Position:
CONTROLLER
Authorized Official Telephone Number:
843-856-7938

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DE1497 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 195942266A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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