Basic Information
| Provider Information | |||||||||
| NPI: | 1083745335 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLY | ||||||||
| FirstName: | ERASME | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 N STATE OF FRANKLIN RD | ||||||||
| Address2: | STE 2 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376043645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239264468 | ||||||||
| FaxNumber: | 4239284838 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 N STATE OF FRANKLIN RD | ||||||||
| Address2: | STE 9 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376043645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239264468 | ||||||||
| FaxNumber: | 4239284838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 02/12/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 049439 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 18820 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 18820 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X | 54651 | TN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | F365496891 | 01 | SC | MEDICARE | OTHER | 060062892 | 01 | SC | MEDICARE RAILROAD | OTHER | 18820 | 01 | SC | STATE ID | OTHER | 188200 | 05 | SC | MEDICAID | 571109147 | 01 | SC | TAX ID | OTHER | 11BDVMH | 01 | GA | MEDICARE | OTHER |