Provider Demographics
NPI:1538440516
Name:J.R. COLLIP, M.D., LLC.
Entity type:Organization
Organization Name:J.R. COLLIP, M.D., LLC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RALPH
Authorized Official - Last Name:COLLIP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-763-0212
Mailing Address - Street 1:PO BOX 438
Mailing Address - Street 2:219 EAST MAIN STREET
Mailing Address - City:MORRISTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46161-0438
Mailing Address - Country:US
Mailing Address - Phone:765-763-0212
Mailing Address - Fax:765-763-0210
Practice Address - Street 1:219 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:IN
Practice Address - Zip Code:46161-0438
Practice Address - Country:US
Practice Address - Phone:765-763-0212
Practice Address - Fax:765-763-0210
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:J.R. COLLIP, M.D., LLC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-02
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044478A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2000725208Medicaid
IN2000725208Medicaid