MEDICARE: COLLABORATIVE GERIATRICS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QG0300X	Geriatric Medicine (Family Medicine) Physician	21327	WV
2	207QG0300X	Geriatric Medicine (Family Medicine) Physician	1601	WV
3	207QG0300X	Geriatric Medicine (Family Medicine) Physician	20005	WV
4	207QG0300X	Geriatric Medicine (Family Medicine) Physician	14713	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629004221
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLLABORATIVE GERIATRICS, INC.

Provider Business Mailing Address
First Line	:	PO BOX 979
Second Line	:
City	:	CULLODEN
State	:	WV
Zip	:	25510-0979
Country	:	US
Telephone Number	:	304-743-8007
Fax Number	:	304-743-1704

Provider Business Practice Location Address
First Line	:	414 MAHOGANYWOOD DR
Second Line	:
City	:	MILTON
State	:	WV
Zip	:	25541-1181
Country	:	US
Telephone Number	:	304-743-8007
Fax Number	:	304-743-1704

Authorized Official
Title or Position	:	ADMINISTRATIVE ASSISTANT
Name	:	COURTNEY BROOKE TAYLOR
Credential	:
Telephone Number	:	304-743-8007

Provider Enumeration Date	:	06/24/2006
Last Update Date	:	08/22/2020

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Directions to “COLLABORATIVE GERIATRICS, INC. ” Practice Location

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