Provider Demographics
NPI:1003855917
Name:CENTER FOR COLORECTAL CARE LLC
Entity Type:Organization
Organization Name:CENTER FOR COLORECTAL CARE LLC
Other - Org Name:
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:678-344-6303
Mailing Address - Street 1:1800 TREE LN
Mailing Address - Street 2:SUITE 270
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-2016
Mailing Address - Country:US
Mailing Address - Phone:678-344-6303
Mailing Address - Fax:
Practice Address - Street 1:1800 TREE LN
Practice Address - Street 2:SUITE 270
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2016
Practice Address - Country:US
Practice Address - Phone:678-344-6303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADC6649Medicare ID - Type UnspecifiedRR MEDICARE
GAGRP6881Medicare ID - Type Unspecified