MEDICARE: NEHDRA MCCOLLUM

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	305R00000X	Preferred Provider Organization

General Provider Information

NPI Number	:	1942659537
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEHDRA MCCOLLUM

Provider Business Mailing Address
First Line	:	5008 EAST 86 ST
Second Line	:
City	:	GARFIELD HTS
State	:	OH
Zip	:	44125
Country	:	US
Telephone Number	:	216-396-8203
Fax Number	:

Provider Business Practice Location Address
First Line	:	5008 E 86TH ST
Second Line	:
City	:	GARFIELD HTS
State	:	OH
Zip	:	44125-2000
Country	:	US
Telephone Number	:	216-396-8203
Fax Number	:

Authorized Official
Title or Position	:	INDEPENDENT PROVIDER
Name	:	MRS. NEHDRA MONIQUE MCCOLLUM
Credential	:	02/18/2016
Telephone Number	:	216-396-8203

Provider Enumeration Date	:	06/06/2016
Last Update Date	:	06/06/2016

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