Basic Information
| Provider Information | |||||||||
| NPI: | 1699240531 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLUMBUS AMBULATORY HEALTHCARE SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 117337 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303687337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708012500 | ||||||||
| FaxNumber: | 4702712895 | ||||||||
| Practice Location | |||||||||
| Address1: | 1810 STADIUM DR STE 240 | ||||||||
| Address2: | |||||||||
| City: | PHENIX CITY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 368673179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342918303 | ||||||||
| FaxNumber: | 3342918325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2018 | ||||||||
| LastUpdateDate: | 10/26/2021 | ||||||||
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| AuthorizedOfficialLastName: | WALKER | ||||||||
| AuthorizedOfficialFirstName: | TEIRRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 7064944300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COLUMBUS AMBULATORY HEALTHCARE SERVICES, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 10/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.