Provider Demographics
NPI:1235115593
Name:COLLERAN, KEVIN R (MD)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:R
Last Name:COLLERAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:100 NORTH ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-961-3823
Mailing Address - Fax:570-207-5988
Practice Address - Street 1:3 W OLIVE ST
Practice Address - Street 2:STE 118
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18508-2572
Practice Address - Country:US
Practice Address - Phone:570-961-3823
Practice Address - Fax:570-207-5988
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2020-07-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMD421827207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
070093FE4Medicare PIN
H85435Medicare UPIN