=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295931434
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RICHARD D. COLLISON, M.D.,P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2007
-----------------------------------------------------
Last Update Date | 09/13/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1003 WILLOW CREEK RD
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86301-1641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-778-5443
-----------------------------------------------------
Fax | 928-443-1572
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2860
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86302-2860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-778-5443
-----------------------------------------------------
Fax | 928-443-1572
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RICHARD DAVIS COLLISON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 928-778-5443
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 15632
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------