Provider Demographics
NPI:1013053115
Name:PHYSCIANS IMMEDIATE MED OF CANTON, PC
Entity Type:Organization
Organization Name:PHYSCIANS IMMEDIATE MED OF CANTON, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:COOLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-720-7000
Mailing Address - Street 1:720 TRANSIT AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-2571
Mailing Address - Country:US
Mailing Address - Phone:770-720-7000
Mailing Address - Fax:770-720-7055
Practice Address - Street 1:720 TRANSIT AVE STE 101
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2571
Practice Address - Country:US
Practice Address - Phone:770-720-7000
Practice Address - Fax:770-720-7055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035839261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care