Basic Information
| Provider Information | |||||||||
| NPI: | 1871855502 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLACCHIO | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | DOMINIC | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 BUCKNAM RD STE 1D | ||||||||
| Address2: | |||||||||
| City: | FALMOUTH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041051208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077811551 | ||||||||
| FaxNumber: | 2077811552 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 BUCKNAM RD STE 1D | ||||||||
| Address2: | |||||||||
| City: | FALMOUTH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041051208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077811551 | ||||||||
| FaxNumber: | 2077811552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2012 | ||||||||
| LastUpdateDate: | 12/03/2018 | ||||||||
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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 | 207X00000X | MD21891 | ME | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | 2017-00044 | NC | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2017-00044 | 01 | NC | MEDICAL LICENSE | OTHER |