Provider Demographics
NPI:1225019367
Name:KOLL, BRIAN (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:KOLL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HARWICH PORT
Mailing Address - State:MA
Mailing Address - Zip Code:02646-1931
Mailing Address - Country:US
Mailing Address - Phone:508-905-2800
Mailing Address - Fax:774-209-3228
Practice Address - Street 1:710 MAIN ST
Practice Address - Street 2:
Practice Address - City:HARWICH PORT
Practice Address - State:MA
Practice Address - Zip Code:02646-1931
Practice Address - Country:US
Practice Address - Phone:508-905-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175611207R00000X, 207RI0200X
MA276952207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01475938Medicaid
F69347Medicare UPIN
NY01475938Medicaid