Basic Information
| Provider Information | |||||||||
| NPI: | 1649475930 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLQUITT REGIONAL ORTHOPEDICS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2169 | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317762169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2298919131 | ||||||||
| FaxNumber: | 2298919079 | ||||||||
| Practice Location | |||||||||
| Address1: | 3131 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317686925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2298919131 | ||||||||
| FaxNumber: | 2298919079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | RICKS | ||||||||
| AuthorizedOfficialFirstName: | JUDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 2298919131 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.