Basic Information
| Provider Information | |||||||||
| NPI: | 1306892039 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOLODZIK | ||||||||
| FirstName: | JOAN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 HEMPSTEAD STATION DR | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454295164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008750136 | ||||||||
| FaxNumber: | 9376194381 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450052584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5133123656 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 06/10/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35055905 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000315972 | 01 | OH | BCBS FOR UVMC | OTHER | 0713973 | 05 | OH | MEDICAID | 000000317227 | 01 | OH | BCBS | OTHER | P00114921 | 01 | RR MEDICARE FOR UMVC | OTHER |