Provider Demographics
NPI:1851348692
Name:COLWILL, JACK M (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:M
Last Name:COLWILL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:573-884-3300
Mailing Address - Fax:573-884-0943
Practice Address - Street 1:551 VETERANS UNITED DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8397
Practice Address - Country:US
Practice Address - Phone:573-884-7733
Practice Address - Fax:573-882-6228
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR2704207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO11756OtherBLUE SHIELD
MO2086319101OtherKANSAS MEDICAID
MO102431OtherHEALTLINK
MO104116OtherUNITED HEALTHCARE
MO200467009Medicaid
ME11756OtherBLUE CHOICE
MOA12969Medicare UPIN
MO11756OtherBLUE SHIELD
MO104116OtherUNITED HEALTHCARE
MO967835236Medicare PIN