Healthcare Provider Details

I. General information

NPI: 1992779342
Provider Name (Legal Business Name): THOMAS A COLLENTINE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 03/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 OLDE TOWNE PKWY STE 150A
MARIETTA GA
30068-4357
US

IV. Provider business mailing address

4800 OLDE TOWNE PKWY STE 150A
MARIETTA GA
30068-4357
US

V. Phone/Fax

Practice location:
  • Phone: 770-509-1025
  • Fax: 770-509-1884
Mailing address:
  • Phone: 770-509-1025
  • Fax: 770-509-1884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number016568
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: