=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013053115
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSCIANS IMMEDIATE MED OF CANTON, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 720 TRANSIT AVE STE 101
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30114-2571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-720-7000
-----------------------------------------------------
Fax | 770-720-7055
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 720 TRANSIT AVE STE 101
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30114-2571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-720-7000
-----------------------------------------------------
Fax | 770-720-7055
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CHARLES R COOLEY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 770-720-7000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number | 035839
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------