Healthcare Provider Details

I. General information

NPI: 1336140987
Provider Name (Legal Business Name): COLLIS, KIM & ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 EAGLE VALLEY CT SUITE 101
BROADVIEW HTS OH
44147-2982
US

IV. Provider business mailing address

PO BOX 94832
CLEVELAND OH
44101-4832
US

V. Phone/Fax

Practice location:
  • Phone: 440-746-1055
  • Fax: 440-746-1052
Mailing address:
  • Phone: 216-464-5160
  • Fax: 216-464-5982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number StateOH

VIII. Authorized Official

Name: JOHN S COLLIS JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 440-746-1055