Healthcare Provider Details

I. General information

NPI: 1386671998
Provider Name (Legal Business Name): CHARLES COY LASSITER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 01/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 TOWER RD NE SUITE 200
MARIETTA GA
30060-9411
US

IV. Provider business mailing address

400 TOWER RD NE SUITE 200
MARIETTA GA
30060-9411
US

V. Phone/Fax

Practice location:
  • Phone: 770-514-7550
  • Fax: 770-514-1390
Mailing address:
  • Phone: 770-514-7550
  • Fax: 770-514-1390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number052984
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number052984
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number052984
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: