Healthcare Provider Details

I. General information

NPI: 1568532240
Provider Name (Legal Business Name): COLLYER EKHOLM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 12/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 11TH ST NW
CEDAR RAPIDS IA
52405-3811
US

IV. Provider business mailing address

PO BOX 17779
PHOENIX AZ
85011-0779
US

V. Phone/Fax

Practice location:
  • Phone: 319-398-3562
  • Fax: 319-398-3501
Mailing address:
  • Phone: 602-374-7522
  • Fax: 602-237-6997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number24583
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number28026
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number18871
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: