1710070305 NPI number — GREGORY MATHEW KOLAR MS ED

Table of content: GREGORY MATHEW KOLAR MS ED (NPI 1710070305)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710070305 NPI number — GREGORY MATHEW KOLAR MS ED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOLAR
Provider First Name:
GREGORY
Provider Middle Name:
MATHEW
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS ED
Provider Gender Code:
M

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:
1710070305
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4555 W SCHROEDER DRIVE
Provider Second Line Business Mailing Address:
SUITE 170
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-365-3210
Provider Business Mailing Address Fax Number:
414-365-3225

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 E WALDO BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANITOWOC
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-682-6087
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/02/2006

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: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 40969400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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