Basic Information
| Provider Information | |||||||||
| NPI: | 1760422869 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOLODZIK | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | W | ||||||||
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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: | 9376194231 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 MIRABEAU ST | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451231617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379812216 | ||||||||
| FaxNumber: | 9379819238 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 03/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35052684 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0608006 | 05 | OH | MEDICAID | 000000537070 | 01 | OH | ANTHEM | OTHER | P00206144 | 01 | RAIL ROAD MEDICARE | OTHER | 201007380 | 05 | KY | MEDICAID | P00111883 | 01 | RAILROAD MEDICARE | OTHER | 000000329196 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 000000315973 | 01 | BCBS FOR UVMC | OTHER | 000000316737 | 01 | OH | BCBS | OTHER | 000000351194 | 01 | OH | ANTHEM BCBS/MARYSVILLE | OTHER | 000000531260 | 01 | OH | ANTHEM | OTHER | P00441746 | 01 | OH | MEDICARE RAILROAD | OTHER | P00307842 | 01 | RR MEDICARE FOR UVMC | OTHER |