Basic Information
| Provider Information | |||||||||
| NPI: | 1194088716 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COOSA RIVER EMERGENCY PHYSICIANS, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 31328 | ||||||||
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| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37040 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 E 100TH STREET | ||||||||
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| City: | ANNISTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562355121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2012 | ||||||||
| LastUpdateDate: | 06/19/2012 | ||||||||
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| AuthorizedOfficialLastName: | GREEN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 9316146379 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.