Basic Information
| Provider Information | |||||||||
| NPI: | 1548346224 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLEMAN | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | H. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13428 | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314160428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123503849 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4700 WATERS AVE | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314046220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123503849 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 05/06/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0204X | MD00043043 | WA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 207PP0204X | 060360 | GA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8424723 | 05 | WA | MEDICAID | N426895 | 01 | GA | NONPAR WELLCARE | OTHER | 295110 | 01 | INTERNAL ID-MOTOR VEHICLE ID | OTHER | 01170543 | 01 | GA | AMERIGROUP | OTHER | 222775448A | 05 | GA | MEDICAID | G60361 | 05 | SC | MEDICAID | 1548346224 | 01 | GA | PEACHSTATE HEALTH PLAN | OTHER |