Healthcare Provider Details

I. General information

NPI: 1831277987
Provider Name (Legal Business Name): COBB MEDICAL ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 03/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3903 S COBB DR SE SUITE 200
SMYRNA GA
30080-6342
US

IV. Provider business mailing address

3903 S COBB DR SE SUITE 200
SMYRNA GA
30080-6342
US

V. Phone/Fax

Practice location:
  • Phone: 770-437-6910
  • Fax: 770-433-2380
Mailing address:
  • Phone: 770-437-6910
  • Fax: 770-433-2380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateGA

VIII. Authorized Official

Name: DONNA JETER
Title or Position: MANAGER
Credential:
Phone: 770-437-6910