MEDICARE: PHILOMENA MARIE COLUCCI D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RH0003X	Hematology & Oncology Physician	03043	KY

General Provider Information

NPI Number	:	1811012438
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILOMENA MARIE COLUCCI D.O.

Provider Business Mailing Address
First Line	:	829 N CENTER AVE
Second Line	:	SUITE 298
City	:	GAYLORD
State	:	MI
Zip	:	49735-1595
Country	:	US
Telephone Number	:	989-731-7708
Fax Number	:	989-731-7929

Provider Business Practice Location Address
First Line	:	701 N OTSEGO AVE
Second Line	:
City	:	GAYLORD
State	:	MI
Zip	:	49735-1558
Country	:	US
Telephone Number	:	989-731-7760
Fax Number	:	989-731-7748

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	11/15/2013

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