Provider Demographics
NPI:1609045798
Name:BALL GROUND FAMILY PRACTICE,P.C.
Entity Type:Organization
Organization Name:BALL GROUND FAMILY PRACTICE,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:L
Authorized Official - Last Name:COSTER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:770-735-6755
Mailing Address - Street 1:PO BOX 127
Mailing Address - Street 2:
Mailing Address - City:BALL GROUND
Mailing Address - State:GA
Mailing Address - Zip Code:30107-0127
Mailing Address - Country:US
Mailing Address - Phone:770-735-6755
Mailing Address - Fax:770-735-4528
Practice Address - Street 1:255 GILMER FERRY RD
Practice Address - Street 2:
Practice Address - City:BALL GROUND
Practice Address - State:GA
Practice Address - Zip Code:30107-2908
Practice Address - Country:US
Practice Address - Phone:770-735-6755
Practice Address - Fax:770-735-4528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045754207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6371Medicare PIN