Provider Demographics
NPI:1922171081
Name:COBB GYN CLINIC, P.C.
Entity Type:Organization
Organization Name:COBB GYN CLINIC, P.C.
Other - Org Name:COBB GYN CLINIC, P.A.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:L
Authorized Official - Last Name:FRANK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-577-7030
Mailing Address - Street 1:3327 HIGHWAY 5
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-2307
Mailing Address - Country:US
Mailing Address - Phone:770-577-7030
Mailing Address - Fax:770-577-6844
Practice Address - Street 1:3327 HIGHWAY 5
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-6844
Practice Address - Country:US
Practice Address - Phone:770-577-7030
Practice Address - Fax:770-577-6844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA015528207Q00000X
GA014251207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00065029AMedicaid
GA00065029AMedicaid