Basic Information
| Provider Information | |||||||||
| NPI: | 1629171582 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | COLEMAN | ||||||||
| MiddleName: | T. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 15TH ST STE BI1056 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309120004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067213813 | ||||||||
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| Practice Location | |||||||||
| Address1: | 587 FURYS FERRY RD | ||||||||
| Address2: | |||||||||
| City: | MARTINEZ | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067218623 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 05/01/2019 | ||||||||
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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 | 207R00000X | 040122 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | G40122 | 05 | SC | MEDICAID | 000669644F | 05 | GA | MEDICAID |