Provider Demographics
NPI:1124200100
Name:COOSA NEUROSURGERY PC
Entity Type:Organization
Organization Name:COOSA NEUROSURGERY PC
Other - Org Name:ROME NEUROSPINAL CENTER PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:H
Authorized Official - Middle Name:
Authorized Official - Last Name:PITTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-238-5465
Mailing Address - Street 1:20 RIVERBEND DR SW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-6066
Mailing Address - Country:US
Mailing Address - Phone:706-238-5465
Mailing Address - Fax:
Practice Address - Street 1:20 RIVERBEND DR SW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-6066
Practice Address - Country:US
Practice Address - Phone:706-238-5465
Practice Address - Fax:706-235-1618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000285271DMedicaid
GA=========OtherTAX ID#
GA511I140005Medicare PIN