Provider Demographics
NPI:1205852480
Name:KOLACZ, PAMELA (MD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:KOLACZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6320 WEDGWOOD RD N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-3647
Mailing Address - Country:US
Mailing Address - Phone:763-268-0400
Mailing Address - Fax:763-268-0405
Practice Address - Street 1:6320 WEDGWOOD RD N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-3647
Practice Address - Country:US
Practice Address - Phone:763-268-0400
Practice Address - Fax:763-268-0405
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN22G83KOOtherBLUE CROSS BLUE SHIELD
MN22G83KOOtherBLUE CROSS BLUE SHIELD
MN080008290Medicare ID - Type UnspecifiedMEDICARE