Provider Demographics
NPI:1043254360
Name:COLISEUM HEALTH GROUP, LLC
Entity type:Organization
Organization Name:COLISEUM HEALTH GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-405-0280
Mailing Address - Street 1:420 CHARTER BLVD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-4854
Mailing Address - Country:US
Mailing Address - Phone:478-405-0280
Mailing Address - Fax:
Practice Address - Street 1:420 CHARTER BLVD
Practice Address - Street 2:SUITE 304
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-4854
Practice Address - Country:US
Practice Address - Phone:478-405-0280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6049Medicare ID - Type UnspecifiedCAHABA MEDICARE/ GA MEDIC
GADA8799Medicare ID - Type UnspecifiedRAILROAD MEDICARE