Provider Demographics
NPI:1336140987
Name:COLLIS, KIM & ASSOCIATES, INC.
Entity Type:Organization
Organization Name:COLLIS, KIM & ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:COLLIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:440-746-1055
Mailing Address - Street 1:PO BOX 94832
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44101-4832
Mailing Address - Country:US
Mailing Address - Phone:216-464-5160
Mailing Address - Fax:216-464-5982
Practice Address - Street 1:1 EAGLE VALLEY CT
Practice Address - Street 2:SUITE 101
Practice Address - City:BROADVIEW HTS
Practice Address - State:OH
Practice Address - Zip Code:44147-2982
Practice Address - Country:US
Practice Address - Phone:440-746-1055
Practice Address - Fax:440-746-1052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207RR0500X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9335642Medicare PIN
OH9335646Medicare PIN
OH9282194Medicare PIN
OH9335641Medicare PIN
OH9282199Medicare PIN
OH9335647Medicare PIN
OH9282198Medicare PIN