Provider Demographics
NPI:1639105612
Name:KOLUDROVICH, DONALD ROBERT (CRNA)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:ROBERT
Last Name:KOLUDROVICH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 N MADISON ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-1143
Mailing Address - Country:US
Mailing Address - Phone:269-781-4271
Mailing Address - Fax:
Practice Address - Street 1:200 N MADISON ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-1143
Practice Address - Country:US
Practice Address - Phone:269-781-4271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704220211367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI432076010Medicaid
MI432076010Medicaid
MI0M83200005Medicare ID - Type Unspecified