Basic Information
| Provider Information | |||||||||
| NPI: | 1609933829 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARTERSVILLE OCCUPATIONAL MEDICINE CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 958 JOE FRANK HARRIS PKWY SE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CARTERSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301202158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703878183 | ||||||||
| FaxNumber: | 7706062127 | ||||||||
| Practice Location | |||||||||
| Address1: | 958 JOE FRANK HARRIS PKWY SE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CARTERSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301202158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7703878183 | ||||||||
| FaxNumber: | 7706062127 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MCDONALD | ||||||||
| AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7703878183 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Occupational Medicine |
No ID Information.