Basic Information
| Provider Information | |||||||||
| NPI: | 1558442087 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLEN | ||||||||
| FirstName: | COLBY | ||||||||
| MiddleName: | MARSHALL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 HIGHWAY 74 S | ||||||||
| Address2: | SUITE 720 | ||||||||
| City: | PEACHTREE CITY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302693081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706326800 | ||||||||
| FaxNumber: | 7706326060 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 HIGHWAY 74 S | ||||||||
| Address2: | SUITE 720 | ||||||||
| City: | PEACHTREE CITY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302693081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706326800 | ||||||||
| FaxNumber: | 7706326060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 11/13/2009 | ||||||||
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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 | 225100000X | 05008605A | IN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 004774 | KY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT009829 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000000064465 | 01 | IN | BCBS | OTHER | 200816690 | 05 | IN | MEDICAID |