Provider Demographics
NPI:1346708708
Name:COLONNA PHYSICIAN SERVICES LLC
Entity Type:Organization
Organization Name:COLONNA PHYSICIAN SERVICES LLC
Other - Org Name:MICHAEL COLONNA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:COLONNA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:928-897-5365
Mailing Address - Street 1:4030 N STOCKTON HILL RD STE 3
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-2452
Mailing Address - Country:US
Mailing Address - Phone:928-897-5365
Mailing Address - Fax:928-443-8941
Practice Address - Street 1:4030 N STOCKTON HILL RD STE 3
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-2452
Practice Address - Country:US
Practice Address - Phone:928-897-5365
Practice Address - Fax:928-443-8941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-05
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty