Basic Information
| Provider Information | |||||||||
| NPI: | 1336665371 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLQUITT REGIONAL INFECTIOUS DISEASE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2438 | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317762438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2298919009 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6 HOSPITAL PARK | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317686700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2298919009 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2017 | ||||||||
| LastUpdateDate: | 08/22/2017 | ||||||||
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| AuthorizedOfficialLastName: | STRANGE | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2298903531 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
No ID Information.