Provider Demographics
NPI:1205812708
Name:KOLLE, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:KOLLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1028 HANNAH AVE
Mailing Address - Street 2:STE D
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-2963
Mailing Address - Country:US
Mailing Address - Phone:231-946-7360
Mailing Address - Fax:231-929-4775
Practice Address - Street 1:1028 HANNAH AVE
Practice Address - Street 2:STE D
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-2963
Practice Address - Country:US
Practice Address - Phone:231-946-7360
Practice Address - Fax:231-929-4775
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004860111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3328683Medicaid
MI0B85010OtherBLUE CROSS BLUE SHIELD OF MI
MI0B85010OtherBLUE CROSS BLUE SHIELD OF MI
MIT96939Medicare UPIN