MEDICARE: HERBERT ROSWELL COLCORD

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	363LP2300X	Primary Care Nurse Practitioner	RN167054	GA

General Provider Information

NPI Number	:	1770065815
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HERBERT ROSWELL COLCORD

Provider Business Mailing Address
First Line	:	4621 BENTLEY PL
Second Line	:
City	:	PEACHTREE CORNERS
State	:	GA
Zip	:	30096-6128
Country	:	US
Telephone Number	:	404-731-3866
Fax Number	:

Provider Business Practice Location Address
First Line	:	3015 LEXINGTON RD
Second Line	:
City	:	ATHENS
State	:	GA
Zip	:	30605-2491
Country	:	US
Telephone Number	:	706-613-3270
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2018
Last Update Date	:	09/05/2018

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Directions to “ HERBERT ROSWELL COLCORD ” Practice Location

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