Basic Information
| Provider Information | |||||||||
| NPI: | 1427316637 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOSEPHINE F COLLACO MD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7550 LUCERNE DR | ||||||||
| Address2: | SUITE 405 | ||||||||
| City: | MIDDLEBURG HTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441306503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005566236 | ||||||||
| FaxNumber: | 4402343313 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 ISAAC STREETS DR | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | OREGON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436163291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196984642 | ||||||||
| FaxNumber: | 4196988597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2012 | ||||||||
| LastUpdateDate: | 04/25/2012 | ||||||||
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| AuthorizedOfficialLastName: | POLO | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
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| AuthorizedOfficialTitleorPosition: | OPERATIONS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4402348833 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35038665 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000162663 | 01 | OH | ANTHEM BLUE CROSS BLUE SHIELD | OTHER |