Provider Demographics
NPI:1023043775
Name:CHANNICK, COLLEEN LUCY (MD)
Entity Type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:LUCY
Last Name:CHANNICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:LUCY
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1223 16TH ST STE 3400
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1279
Practice Address - Country:US
Practice Address - Phone:310-449-0939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64140207R00000X, 207RC0200X, 207RP1001X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A641400Medicaid
CAWA64140MMedicare ID - Type Unspecified
CAWA64140LMedicare ID - Type Unspecified
CAG73969Medicare UPIN