Healthcare Provider Details

I. General information

NPI: 1245599778
Provider Name (Legal Business Name): COREY MICHAEL CARSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2012
Last Update Date: 03/27/2024
Certification Date: 03/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 CHEROKEE ST NE STE 100
MARIETTA GA
30060-8930
US

IV. Provider business mailing address

660 CHEROKEE ST NE
MARIETTA GA
30060-8965
US

V. Phone/Fax

Practice location:
  • Phone: 678-797-8201
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number98617
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number98617
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: