MEDICARE: COOSA MEDICAL GROUP

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	174400000X	Specialist		GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CG3794	OTHER	GA	RAILROAD MEDICARE GROUP#

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
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821046863
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COOSA MEDICAL GROUP

Provider Business Mailing Address
First Line	:	126 THREE RIVERS DR NE
Second Line	:
City	:	ROME
State	:	GA
Zip	:	30161-4999
Country	:	US
Telephone Number	:	706-295-0070
Fax Number	:	706-235-1618

Provider Business Practice Location Address
First Line	:	126 THREE RIVERS DR NE
Second Line	:
City	:	ROME
State	:	GA
Zip	:	30161-4999
Country	:	US
Telephone Number	:	706-295-0070
Fax Number	:	706-235-1618

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. NANCY C SMITH
Credential	:
Telephone Number	:	706-238-5465

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	07/21/2022

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Directions to “COOSA MEDICAL GROUP ” Practice Location

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