Provider Demographics
NPI:1588870802
Name:NANCY R. KOLLISCH, M.D., INC.
Entity type:Organization
Organization Name:NANCY R. KOLLISCH, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:KOLLISCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-296-9883
Mailing Address - Street 1:8008 FROST ST
Mailing Address - Street 2:SUITE 445
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4205
Mailing Address - Country:US
Mailing Address - Phone:619-296-9883
Mailing Address - Fax:619-296-4930
Practice Address - Street 1:8008 FROST ST
Practice Address - Street 2:SUITE 445
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4205
Practice Address - Country:US
Practice Address - Phone:619-296-9883
Practice Address - Fax:619-296-4930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44466207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G444660Medicaid
CA00G444660Medicaid
CAG44466Medicare ID - Type Unspecified