Healthcare Provider Details

I. General information

NPI: 1336256742
Provider Name (Legal Business Name): RICHARD BRIAN COLLIE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 09/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 CHERRY ST SUITE 205
BLUEFIELD WV
24701-3338
US

IV. Provider business mailing address

510 CHERRY ST SUITE 205
BLUEFIELD WV
24701-3338
US

V. Phone/Fax

Practice location:
  • Phone: 304-324-2954
  • Fax: 304-324-2955
Mailing address:
  • Phone: 304-324-2954
  • Fax: 304-324-2955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberDO1630
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: