Basic Information
Provider Information | |||||||||
NPI: | 1306956016 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COLLINS | ||||||||
FirstName: | JASON | ||||||||
MiddleName: | GARRET | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7619 W JEFFERSON BLVD | ||||||||
Address2: |   | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468044133 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2604078000 | ||||||||
FaxNumber: | 2604078004 | ||||||||
Practice Location | |||||||||
Address1: | 2201 LEXINGTON AVE | ||||||||
Address2: |   | ||||||||
City: | ASHLAND | ||||||||
State: | KY | ||||||||
PostalCode: | 411012843 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2604078000 | ||||||||
FaxNumber: | 2604078004 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2006 | ||||||||
LastUpdateDate: | 07/01/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 36862 | KY | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207P00000X | 48622 | TN | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
No ID Information.