Healthcare Provider Details

I. General information

NPI: 1972429454
Provider Name (Legal Business Name): CORALIE MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 VIDAL BLVD
DECATUR GA
30030-2346
US

IV. Provider business mailing address

167 VIDAL BLVD
DECATUR GA
30030-2346
US

V. Phone/Fax

Practice location:
  • Phone: 404-308-0173
  • Fax:
Mailing address:
  • Phone: 404-308-0173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CAROLINE MORGAN BERCHUCK
Title or Position: PHYSICIAN
Credential: MD
Phone: 404-308-0173