Basic Information
| Provider Information | |||||||||
| NPI: | 1033228184 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOLENICH | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 239 EDGEWOOD DRIVE EXT. | ||||||||
| Address2: | |||||||||
| City: | TRANSFER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161549999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7246460400 | ||||||||
| FaxNumber: | 7246460413 | ||||||||
| Practice Location | |||||||||
| Address1: | 239 EDGEWOOD DRIVE EXT. | ||||||||
| Address2: | |||||||||
| City: | TRANSFER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161549999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7246460400 | ||||||||
| FaxNumber: | 7246460413 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 01/26/2009 | ||||||||
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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 | 208600000X | MD016698E | PA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000719501 001 | 05 | PA | MEDICAID | 0351248 | 01 | OH | MEDICAL LICENSE | OTHER | 160899 | 01 | PA | PA BLUE SHIELD | OTHER |