Provider Demographics
NPI:1275592750
Name:COLLAER, REBECCA ANN (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:COLLAER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:212 S SULLIVAN AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-1548
Practice Address - Country:US
Practice Address - Phone:231-924-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301089462208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM28290038Medicare PIN
MIM28290038Medicare PIN
WI32643200Medicaid