Provider Demographics
NPI:1912947367
Name:COLISEUM HEALTH GROUP, LLC
Entity Type:Organization
Organization Name:COLISEUM HEALTH GROUP, LLC
Other - Org Name:COLISEUM PRIMARY HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MICKEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-841-2707
Mailing Address - Street 1:360 HOSPITAL DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-3874
Mailing Address - Country:US
Mailing Address - Phone:478-841-2707
Mailing Address - Fax:
Practice Address - Street 1:360 HOSPITAL DR
Practice Address - Street 2:SUITE 110
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-3874
Practice Address - Country:US
Practice Address - Phone:478-841-2707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherCHAMPUS TRICARE PROGRAM
GA=========OtherCHAMPUS TRICARE PROGRAM
GAGRP5184Medicare ID - Type UnspecifiedCAHABA MEDICARE/ GA MEDIC