Healthcare Provider Details

I. General information

NPI: 1710097571
Provider Name (Legal Business Name): JOHN RALPH COLLIP M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 08/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 W MAIN ST
GREENFIELD IN
46140-2056
US

IV. Provider business mailing address

8268 RED SAIL CT
INDIANAPOLIS IN
46236-9574
US

V. Phone/Fax

Practice location:
  • Phone: 317-679-1009
  • Fax: 317-826-1370
Mailing address:
  • Phone: 317-679-1009
  • Fax: 317-826-1370

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number01044478A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: