Healthcare Provider Details

I. General information

NPI: 1508423328
Provider Name (Legal Business Name): ANTHONY COKER CANTRELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2019
Last Update Date: 08/02/2025
Certification Date: 08/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 NORTHSIDE CHEROKEE BLVD STE 180
CANTON GA
30115-8029
US

IV. Provider business mailing address

450 NORTHSIDE CHEROKEE BLVD
CANTON GA
30115-8015
US

V. Phone/Fax

Practice location:
  • Phone: 770-517-6636
  • Fax: 770-517-6568
Mailing address:
  • Phone: 770-224-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number32640
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number104759
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: