Healthcare Provider Details

I. General information

NPI: 1801845904
Provider Name (Legal Business Name): THEODORE W COLLINS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 01/10/2022
Certification Date: 01/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 E M35
GWINN MI
49841-9160
US

IV. Provider business mailing address

301 EXPLORER ST
GWINN MI
49841-2813
US

V. Phone/Fax

Practice location:
  • Phone: 906-346-9275
  • Fax:
Mailing address:
  • Phone: 906-483-1130
  • Fax: 906-483-1394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0521005
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101015879
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: