Healthcare Provider Details

I. General information

NPI: 1609045798
Provider Name (Legal Business Name): BALL GROUND FAMILY PRACTICE,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2008
Last Update Date: 02/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 GILMER FERRY RD
BALL GROUND GA
30107-2908
US

IV. Provider business mailing address

PO BOX 127
BALL GROUND GA
30107-0127
US

V. Phone/Fax

Practice location:
  • Phone: 770-735-6755
  • Fax: 770-735-4528
Mailing address:
  • Phone: 770-735-6755
  • Fax: 770-735-4528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number045754
License Number StateGA

VIII. Authorized Official

Name: CHARLES L COSTER
Title or Position: PHYSICIAN
Credential: DO
Phone: 770-735-6755