Provider Demographics
NPI:1053384743
Name:DANIEL W. COLLISON MD PLLC
Entity type:Organization
Organization Name:DANIEL W. COLLISON MD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:WOLFE
Authorized Official - Last Name:COLLISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:603-643-7733
Mailing Address - Street 1:63 S MAIN ST
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:HANOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03755-2072
Mailing Address - Country:US
Mailing Address - Phone:603-643-7733
Mailing Address - Fax:603-643-7703
Practice Address - Street 1:63 S MAIN ST
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:HANOVER
Practice Address - State:NH
Practice Address - Zip Code:03755-2072
Practice Address - Country:US
Practice Address - Phone:603-643-7733
Practice Address - Fax:603-643-7703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-11
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1012208Medicaid