Provider Demographics
NPI:1770065815
Name:COLCORD, HERBERT ROSWELL
Entity type:Individual
Prefix:
First Name:HERBERT
Middle Name:ROSWELL
Last Name:COLCORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4621 BENTLEY PL
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CORNERS
Mailing Address - State:GA
Mailing Address - Zip Code:30096-6128
Mailing Address - Country:US
Mailing Address - Phone:404-731-3866
Mailing Address - Fax:
Practice Address - Street 1:3015 LEXINGTON RD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30605-2491
Practice Address - Country:US
Practice Address - Phone:706-613-3270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN167054363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty