Provider Demographics
NPI:1164480661
Name:MCKOLAY, CHARLES F (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:F
Last Name:MCKOLAY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 W SQUARE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-0462
Mailing Address - Country:US
Mailing Address - Phone:586-573-5260
Mailing Address - Fax:
Practice Address - Street 1:11800 E 12 MILE RD
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3472
Practice Address - Country:US
Practice Address - Phone:586-573-5260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012767207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH00394Medicare UPIN