Provider Demographics
NPI:1033522420
Name:CMG1, LLC
Entity Type:Organization
Organization Name:CMG1, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-298-7705
Mailing Address - Street 1:PO BOX 1611
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36868-1611
Mailing Address - Country:US
Mailing Address - Phone:877-298-7705
Mailing Address - Fax:866-837-9033
Practice Address - Street 1:6487 PIERCE CHAPEL RD UNIT 5
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:GA
Practice Address - Zip Code:31820-3554
Practice Address - Country:US
Practice Address - Phone:877-298-7705
Practice Address - Fax:866-837-9033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA56072204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA56072OtherGA LICENSE