Provider Demographics
NPI:1629004221
Name:COLLABORATIVE GERIATRICS, INC.
Entity Type:Organization
Organization Name:COLLABORATIVE GERIATRICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:BROOKE
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-743-8007
Mailing Address - Street 1:PO BOX 979
Mailing Address - Street 2:
Mailing Address - City:CULLODEN
Mailing Address - State:WV
Mailing Address - Zip Code:25510-0979
Mailing Address - Country:US
Mailing Address - Phone:304-743-8007
Mailing Address - Fax:304-743-1704
Practice Address - Street 1:414 MAHOGANYWOOD DR
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:WV
Practice Address - Zip Code:25541-1181
Practice Address - Country:US
Practice Address - Phone:304-743-8007
Practice Address - Fax:304-743-1704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV14713207QG0300X
WV21327207QG0300X
WV1601207QG0300X
WV20005207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0040807000Medicaid
WV0040807000Medicaid