Basic Information
Provider Information | |||||||||
NPI: | 1912902321 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCCOY | ||||||||
FirstName: | FRANK | ||||||||
MiddleName: | P. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD, PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1700 HOSPITAL SOUTH DR | ||||||||
Address2: | STE 300 | ||||||||
City: | AUSTELL | ||||||||
State: | GA | ||||||||
PostalCode: | 301068116 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709442830 | ||||||||
FaxNumber: | 6785817170 | ||||||||
Practice Location | |||||||||
Address1: | 340 KENNESTONE HOSPITAL BLVD | ||||||||
Address2: | STE 200 | ||||||||
City: | MARIETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300601121 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7702815100 | ||||||||
FaxNumber: | 6785817100 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2005 | ||||||||
LastUpdateDate: | 02/07/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 032945 | GA | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 00426797B | 05 | GA |   | MEDICAID | 00426797C | 05 | GA |   | MEDICAID | 00426797G | 05 | GA |   | MEDICAID | 00426797F | 05 | GA |   | MEDICAID |