Basic Information
| Provider Information | |||||||||
| NPI: | 1780644252 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLVARD | ||||||||
| FirstName: | M | ||||||||
| MiddleName: | CLARK | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COLVARD | ||||||||
| OtherFirstName: | MERRIMAN | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | JR. | ||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1604 GUNBARREL RD | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374213125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236482395 | ||||||||
| FaxNumber: | 4236487542 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 BATTLEFIELD PKWY | ||||||||
| Address2: | STE 100 | ||||||||
| City: | RINGGOLD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307365166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068060170 | ||||||||
| FaxNumber: | 7068060200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 03/21/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 028388 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 000318216F | 05 | GA | MEDICAID | 54121 | 01 | BX TN | OTHER | 000318216D | 05 | GA | MEDICAID | 000318216C | 05 | GA | MEDICAID | 060004408 | 01 | RR MEDICARE | OTHER |