Basic Information
Provider Information | |||||||||
NPI: | 1316115538 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COOSA NEUROLOGY PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 20 RIVERBEND DR SW | ||||||||
Address2: |   | ||||||||
City: | ROME | ||||||||
State: | GA | ||||||||
PostalCode: | 301616066 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7062950070 | ||||||||
FaxNumber: | 7062951618 | ||||||||
Practice Location | |||||||||
Address1: | 20 RIVERBEND DR SW | ||||||||
Address2: |   | ||||||||
City: | ROME | ||||||||
State: | GA | ||||||||
PostalCode: | 301616066 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7062950070 | ||||||||
FaxNumber: | 7062951618 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/11/2008 | ||||||||
LastUpdateDate: | 09/11/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SMITH | ||||||||
AuthorizedOfficialFirstName: | NANCY | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICE MGR | ||||||||
AuthorizedOfficialTelephone: | 7062385465 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.