Healthcare Provider Details

I. General information

NPI: 1619921020
Provider Name (Legal Business Name): COLISEUM PARK CANCER TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 08/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 COLISEUM DR SUITE 100
MACON GA
31217-3865
US

IV. Provider business mailing address

3330 PRESTON RIDGE RD SUITE 300
ALPHARETTA GA
30005-4508
US

V. Phone/Fax

Practice location:
  • Phone: 478-742-2278
  • Fax: 478-742-2673
Mailing address:
  • Phone: 770-350-0126
  • Fax: 770-350-6637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: DALE MCCORD
Title or Position: CEO
Credential: MD
Phone: 770-350-0126