Basic Information
| Provider Information | |||||||||
| NPI: | 1154823938 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLQUITT REGIONAL RHEUMATOLOGY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3277 | ||||||||
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| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317763277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2298919131 | ||||||||
| FaxNumber: | 2298919079 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 MAGNOLIA CT | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317686764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2298919088 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2018 | ||||||||
| LastUpdateDate: | 10/21/2019 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTS | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2298919131 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
No ID Information.