Basic Information
| Provider Information | |||||||||
| NPI: | 1154360808 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCOLLUM | ||||||||
| FirstName: | DAVE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 81 | ||||||||
| Address2: | |||||||||
| City: | CHASKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553180081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883983327 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 S MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553871752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524422191 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 12/04/2007 | ||||||||
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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 | 207P00000X | 25697 | MN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0C319MC | 01 | BCBS | OTHER | 0235010 | 01 | PREFERRED ONE | OTHER | 39-03774 | 01 | MEDICA EMERG | OTHER | 933800400 | 05 | MN | MEDICAID | HP13930 | 01 | HEALTH PARTNERS | OTHER | 106062 | 01 | UCARE | OTHER |