Provider Demographics
NPI:1104931336
Name:NGA COLLARD PSC
Entity type:Organization
Organization Name:NGA COLLARD PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIANOWNER
Authorized Official - Prefix:
Authorized Official - First Name:NGA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-765-7676
Mailing Address - Street 1:1239 WOODLAND DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2770
Mailing Address - Country:US
Mailing Address - Phone:270-765-7676
Mailing Address - Fax:270-765-3015
Practice Address - Street 1:1239 WOODLAND DR
Practice Address - Street 2:SUITE 105
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2770
Practice Address - Country:US
Practice Address - Phone:270-765-7676
Practice Address - Fax:270-982-9222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23094207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64331713Medicaid
KY65943649Medicaid
KY9590114600Medicaid
KY9500360400Medicaid
KY0286619Medicare ID - Type UnspecifiedJ. LIDDINGTON
KY0945503Medicare ID - Type UnspecifiedDR. LE
KY9455Medicare ID - Type Unspecified
KYC02314Medicare UPIN
KY9590114600Medicaid
KY64331713Medicaid
KY65943649Medicaid