Provider Demographics
NPI:1629018023
Name:COLISEUM PRIMARY CARE SERVICES, LLC
Entity Type:Organization
Organization Name:COLISEUM PRIMARY CARE SERVICES, LLC
Other - Org Name:COLISEUM MEDICAL GROUP-NORTHSIDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:TURNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-856-7938
Mailing Address - Street 1:PO BOX 403570
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-3570
Mailing Address - Country:US
Mailing Address - Phone:478-474-4343
Mailing Address - Fax:844-664-2283
Practice Address - Street 1:380 HOSPITAL DR
Practice Address - Street 2:BLDG A SUITE 370
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-8001
Practice Address - Country:US
Practice Address - Phone:478-474-4343
Practice Address - Fax:844-664-2283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADE1497OtherRAILROAD MEDICARE
GA195942266AMedicaid
GA=========OtherCHAMPUS TRICARE PROGRAM
GAGRP7193Medicare PIN