Provider Demographics
NPI:1780637264
Name:KOLICH, LOUIS M (CRNA)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:M
Last Name:KOLICH
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 1:255 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2218
Mailing Address - Country:US
Mailing Address - Phone:517-787-6440
Mailing Address - Fax:
Practice Address - Street 1:4665 DOUGLAS CIR NW
Practice Address - Street 2:SUITE 101
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-3673
Practice Address - Country:US
Practice Address - Phone:330-499-5700
Practice Address - Fax:330-498-4229
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN165413367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0787895Medicaid
430012595OtherMEDICARE RAILROAD
000000213639OtherANTHEM
OH8211981Medicare PIN