1417072018 NPI number — MRS. SUNDRA KOLLIE M.S.

Table of content: MRS. SUNDRA KOLLIE M.S. (NPI 1417072018)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417072018 NPI number — MRS. SUNDRA KOLLIE M.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOLLIE
Provider First Name:
SUNDRA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417072018
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12722 WOODMONT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48227-1290
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-653-0344
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13220 WOODWARD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIGHLAND PARK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48203-3610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-868-1946
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  1-02360 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3022440 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com