Provider Demographics
NPI:1518096767
Name:COLLIE, ANN VIRAE (DO)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:VIRAE
Last Name:COLLIE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 W 12TH ST STE 202
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-1654
Mailing Address - Country:US
Mailing Address - Phone:765-475-8703
Mailing Address - Fax:765-475-8702
Practice Address - Street 1:285 W 12TH ST STE 202
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1654
Practice Address - Country:US
Practice Address - Phone:765-475-8703
Practice Address - Fax:765-475-8702
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201775207R00000X, 207RE0101X
IN02002938A207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA3168998OtherUHC/MAMSI
NC5906049Medicaid
IN200907500Medicaid
VA1518096767Medicaid
VA10022013OtherSENTARA/OPTIMA
VA304619OtherANTHEM