Healthcare Provider Details

I. General information

NPI: 1821046863
Provider Name (Legal Business Name): COOSA MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 THREE RIVERS DR NE
ROME GA
30161-4999
US

IV. Provider business mailing address

126 THREE RIVERS DR NE
ROME GA
30161-4999
US

V. Phone/Fax

Practice location:
  • Phone: 706-295-0070
  • Fax: 706-235-1618
Mailing address:
  • Phone: 706-295-0070
  • Fax: 706-235-1618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. NANCY C SMITH
Title or Position: OFFICE MANAGER
Credential:
Phone: 706-238-5465