Provider Demographics
NPI:1639570328
Name:COLQUITT REGIONAL SPINE LLC
Entity Type:Organization
Organization Name:COLQUITT REGIONAL SPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-891-9131
Mailing Address - Street 1:8 LIVE OAK CT
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-6783
Mailing Address - Country:US
Mailing Address - Phone:229-890-6612
Mailing Address - Fax:
Practice Address - Street 1:8 LIVE OAK CT
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6783
Practice Address - Country:US
Practice Address - Phone:229-890-6612
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-12
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty