Provider Demographics
NPI:1003469495
Name:CLINICAL COLLEAGUES OF INDIANA PC
Entity Type:Organization
Organization Name:CLINICAL COLLEAGUES OF INDIANA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KURT
Authorized Official - Middle Name:
Authorized Official - Last Name:ZUMWALT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-429-6115
Mailing Address - Street 1:1765 E NINE MILE RD STE 1-229
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-5479
Mailing Address - Country:US
Mailing Address - Phone:410-429-6115
Mailing Address - Fax:
Practice Address - Street 1:500 ARCADE AVE STE 100
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2478
Practice Address - Country:US
Practice Address - Phone:800-927-0002
Practice Address - Fax:603-893-8886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-24
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty