MEDICARE: PAMELA KOLACZ M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	42205	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	22G83KO	OTHER	MN	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1205852480
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAMELA KOLACZ M.D.

Provider Business Mailing Address
First Line	:	6320 WEDGWOOD RD N
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55311-3647
Country	:	US
Telephone Number	:	763-268-0400
Fax Number	:	763-268-0405

Provider Business Practice Location Address
First Line	:	6320 WEDGWOOD RD N
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55311-3647
Country	:	US
Telephone Number	:	763-268-0400
Fax Number	:	763-268-0405

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2006
Last Update Date	:	04/13/2012

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