Provider Demographics
NPI:1841396090
Name:KENNETH R KOLLMEYER MD PA
Entity Type:Organization
Organization Name:KENNETH R KOLLMEYER MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:R
Authorized Official - Last Name:KOLLMEYER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-946-5165
Mailing Address - Street 1:221 W COLORADO BLVD
Mailing Address - Street 2:SUITE 625
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-2363
Mailing Address - Country:US
Mailing Address - Phone:214-946-5165
Mailing Address - Fax:
Practice Address - Street 1:221 W COLORADO BLVD
Practice Address - Street 2:SUITE 625
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-2363
Practice Address - Country:US
Practice Address - Phone:214-946-5165
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00345XMedicare ID - Type Unspecified