=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033627930
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIDGET COLLINS, MD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2018
-----------------------------------------------------
Last Update Date | 04/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3175 ELUA ST STE C
-----------------------------------------------------
City | LIHUE
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96766-1203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-212-9867
-----------------------------------------------------
Fax | 434-333-7504
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5903 KIINANI PL
-----------------------------------------------------
City | KAPAA
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96746-9707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-212-9867
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BRIDGET MAUREEN COLLINS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 808-212-9867
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD-12374
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------