Provider Demographics
NPI:1205979952
Name:EAST COBB URGENT CARE, LLC
Entity type:Organization
Organization Name:EAST COBB URGENT CARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SVP OF OUTPATIENT SERVICES, TENET
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:KYLE
Authorized Official - Last Name:BURTNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-893-2153
Mailing Address - Street 1:1445 ROSS AVE
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75202-2711
Mailing Address - Country:US
Mailing Address - Phone:770-971-5494
Mailing Address - Fax:
Practice Address - Street 1:1401 JOHNSON FERRY RD
Practice Address - Street 2:SUITE 390
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-6495
Practice Address - Country:US
Practice Address - Phone:770-971-5494
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GRP6845Medicare PIN