Provider Demographics
NPI:1497841845
Name:KOLACZEWSKI, GAYLEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:GAYLEEN
Middle Name:
Last Name:KOLACZEWSKI
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 1:265 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MUNROE FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44262
Mailing Address - Country:US
Mailing Address - Phone:330-686-3038
Mailing Address - Fax:330-686-2530
Practice Address - Street 1:265 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MUNROE FALLS
Practice Address - State:OH
Practice Address - Zip Code:44262
Practice Address - Country:US
Practice Address - Phone:330-686-3038
Practice Address - Fax:330-686-2530
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35049229207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0640953Medicaid
OHA82580Medicare UPIN
OHKO0590821Medicare PIN