Healthcare Provider Details

I. General information

NPI: 1619327954
Provider Name (Legal Business Name): COLIN MYCHAK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2016
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 IMPERIAL DR STE 102
HAGERSTOWN MD
21740-6555
US

IV. Provider business mailing address

201 DEFENSE HWY STE 205
ANNAPOLIS MD
21401-7096
US

V. Phone/Fax

Practice location:
  • Phone: 855-527-7246
  • Fax: 866-229-5063
Mailing address:
  • Phone: 855-527-7246
  • Fax: 866-229-5063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number202103319
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberH0100176
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: