Basic Information
| Provider Information | |||||||||
| NPI: | 1902213846 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLQUITT REGIONAL SURGERY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 LIVE OAK COURT | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317686783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299851080 | ||||||||
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| Address1: | 4 LIVE OAK COURT | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317686783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299851080 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2014 | ||||||||
| LastUpdateDate: | 07/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTS | ||||||||
| AuthorizedOfficialFirstName: | AMANDA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2298919131 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.