Provider Demographics
NPI:1720013378
Name:KOLLECK, MATHIAS A II (MD)
Entity Type:Individual
Prefix:
First Name:MATHIAS
Middle Name:A
Last Name:KOLLECK
Suffix:II
Gender:M
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:PO BOX 3407
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47733-3407
Mailing Address - Country:US
Mailing Address - Phone:812-450-6815
Mailing Address - Fax:812-450-6822
Practice Address - Street 1:600 MARY ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47747-0001
Practice Address - Country:US
Practice Address - Phone:812-450-7338
Practice Address - Fax:812-450-2193
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052471A208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000109144OtherBCBS - ER MARY STREET
IN000000173755OtherBCBS - CARE GROUP MARY ST
IN000000386245OtherBCBS - CARE GROUP GATEWAY
KY64014269Medicaid
KY64014269Medicaid
IN000000386245OtherBCBS - CARE GROUP GATEWAY
IN639620RMedicare ID - Type UnspecifiedMCARE - CARE GROUP