Provider Demographics
NPI:1023435666
Name:COLQUITT REGIONAL NEUROLOGY, LLC
Entity type:Organization
Organization Name:COLQUITT REGIONAL NEUROLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:
Authorized Official - Last Name:MERDIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-890-3531
Mailing Address - Street 1:PO BOX 1387
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-1387
Mailing Address - Country:US
Mailing Address - Phone:229-502-9735
Mailing Address - Fax:229-502-9733
Practice Address - Street 1:780 26TH AVE SE
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6799
Practice Address - Country:US
Practice Address - Phone:229-502-9735
Practice Address - Fax:229-502-9733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-20
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G704225OtherMEDICARE GROUP PTAN