Provider Demographics
NPI:1992779342
Name:COLLENTINE, THOMAS A (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:COLLENTINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 OLDE TOWNE PKWY STE 150A
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30068-4357
Mailing Address - Country:US
Mailing Address - Phone:770-509-1025
Mailing Address - Fax:770-509-1884
Practice Address - Street 1:4800 OLDE TOWNE PKWY STE 150A
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30068-4357
Practice Address - Country:US
Practice Address - Phone:770-509-1025
Practice Address - Fax:770-509-1884
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016568207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000243746Medicaid
GAD29161Medicare UPIN