Provider Demographics
NPI:1457533762
Name:KOLETTIS KREW LLC
Entity Type:Organization
Organization Name:KOLETTIS KREW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:KOLETTIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:727-738-8410
Mailing Address - Street 1:701 N. HERCULES AVE
Mailing Address - Street 2:STE. B
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33765-2029
Mailing Address - Country:US
Mailing Address - Phone:727-738-8410
Mailing Address - Fax:727-734-6254
Practice Address - Street 1:701 N. HERCULES AVE
Practice Address - Street 2:STE B
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-2029
Practice Address - Country:US
Practice Address - Phone:727-738-8410
Practice Address - Fax:727-734-6254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0007623174400000X
FL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL46556OtherBCBS
FL2161129OtherAETNA
FL255469100Medicaid
AG041Medicare PIN
FL2161129OtherAETNA