Basic Information
| Provider Information | |||||||||
| NPI: | 1598719643 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLISEUM MEDICAL CENTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PIEDMONT MACON MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312173838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787657000 | ||||||||
| FaxNumber: | 4787421247 | ||||||||
| Practice Location | |||||||||
| Address1: | C/O COLISEUM HEALTH SYSTEM | ||||||||
| Address2: | 350 HOSPITAL DRIVE | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787657000 | ||||||||
| FaxNumber: | 4787421247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 08/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | CROSS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | VP GOVERNMENT REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 4702713401 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1729302 | 05 | LA | MEDICAID | 00000459A | 05 | GA | MEDICAID | 203375 | 01 | FL | FLORIDA MEDICAID HMO | OTHER | 3522 | 01 | GA | BLUE CROSS | OTHER | 25706 | 05 | MI | MEDICAID | 4103009 | 05 | NJ | MEDICAID | 166202500 | 01 | DEPT OF LABOR | OTHER | 200461450A | 05 | IN | MEDICAID | 912181100 | 05 | FL | MEDICAID | HOS0164N | 05 | AL | MEDICAID |