Provider Demographics
NPI:1154363745
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:MICKEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-373-7600
Mailing Address - Street 1:110 STONE BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:GA
Mailing Address - Zip Code:31032-5865
Mailing Address - Country:US
Mailing Address - Phone:478-986-4743
Mailing Address - Fax:
Practice Address - Street 1:110 STONE BROOKE DR
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:GA
Practice Address - Zip Code:31032-5865
Practice Address - Country:US
Practice Address - Phone:478-986-4743
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACN6965OtherRAILROAD MEDICARE
GAGRP3184Medicare PIN
GACN6965OtherRAILROAD MEDICARE