Healthcare Provider Details

I. General information

NPI: 1811012438
Provider Name (Legal Business Name): PHILOMENA MARIE COLUCCI D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 11/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N OTSEGO AVE
GAYLORD MI
49735-1558
US

IV. Provider business mailing address

829 N CENTER AVE SUITE 298
GAYLORD MI
49735-1595
US

V. Phone/Fax

Practice location:
  • Phone: 989-731-7760
  • Fax: 989-731-7748
Mailing address:
  • Phone: 989-731-7708
  • Fax: 989-731-7929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number03043
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: