Healthcare Provider Details

I. General information

NPI: 1477560530
Provider Name (Legal Business Name): DEAN STANLEY COLLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 06/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 E BROADWAY STE 250
LOUISVILLE KY
40202-3700
US

IV. Provider business mailing address

315 E BROADWAY STE 250
LOUISVILLE KY
40202-3700
US

V. Phone/Fax

Practice location:
  • Phone: 502-589-4765
  • Fax: 502-589-4799
Mailing address:
  • Phone: 502-589-4765
  • Fax: 502-589-4799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number32071
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: