Healthcare Provider Details

I. General information

NPI: 1184982134
Provider Name (Legal Business Name): BROOKE AUGUSTIN-COLEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BROOKE AUGUSTIN MD

II. Dates (important events)

Enumeration Date: 04/27/2012
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 HIGHWAY 54 W
FAYETTEVILLE GA
30214-4526
US

IV. Provider business mailing address

2608 DANFORTH LN
DECATUR GA
30033-2213
US

V. Phone/Fax

Practice location:
  • Phone: 770-719-6911
  • Fax:
Mailing address:
  • Phone: 651-238-6659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD.34125
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number76290
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: