Basic Information
| Provider Information | |||||||||
| NPI: | 1669467262 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COLLIER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | REGINALD | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2520 ABERDEEN BLVD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280540635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048688400 | ||||||||
| FaxNumber: | 7048688493 | ||||||||
| Practice Location | |||||||||
| Address1: | 2520 ABERDEEN BLVD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280540635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048688400 | ||||||||
| FaxNumber: | 7048688493 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 21759 | NC | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 2019464 | 01 | NC | AETNA HEALTHCARE | OTHER | N21759 | 01 | SC | SOUTH CAROLINA MEDICAID | OTHER | 1549303004 | 01 | NC | CIGNA HEALTHCARE | OTHER | 23777 | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | 53853 | 01 | NC | MEDCOST | OTHER | 8923777 | 05 | NC | MEDICAID | 10-41172 | 01 | NC | UNITED HEALTHCARE | OTHER | 168236 | 01 | NC | MIDSOUTH INS | OTHER | 2103803 | 01 | NC | MAMSI | OTHER | 343001 | 01 | NC | COVENTRY HEALTHCARE | OTHER | 10309 | 01 | NC | PARTNERS HEALTHPLAN | OTHER |