Provider Demographics
NPI:1528007697
Name:COMPREHENSIVE GERIATRIC SERVICES INC PC
Entity Type:Organization
Organization Name:COMPREHENSIVE GERIATRIC SERVICES INC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROMAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KOLODCHIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:586-755-4433
Mailing Address - Street 1:4437 MCKINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-1160
Mailing Address - Country:US
Mailing Address - Phone:586-524-0672
Mailing Address - Fax:
Practice Address - Street 1:26811 RYAN RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-4075
Practice Address - Country:US
Practice Address - Phone:586-755-4433
Practice Address - Fax:586-755-6655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-05
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0M24700Medicare ID - Type UnspecifiedMD PROVIDER NUMBER