Provider Demographics
NPI:1255484515
Name:BRIAN KOLUDROVICH,DPM,LLC
Entity Type:Organization
Organization Name:BRIAN KOLUDROVICH,DPM,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:KOLUDROVICH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:216-475-1324
Mailing Address - Street 1:12000 MCCRACKEN RD
Mailing Address - Street 2:SUITE 157
Mailing Address - City:GARFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-2964
Mailing Address - Country:US
Mailing Address - Phone:216-475-1324
Mailing Address - Fax:216-475-1336
Practice Address - Street 1:12000 MCCRACKEN RD
Practice Address - Street 2:SUITE 157
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2964
Practice Address - Country:US
Practice Address - Phone:216-475-1324
Practice Address - Fax:216-475-1336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5909460002Medicare NSC