Provider Demographics
NPI:1528344157
Name:COLLEEN NIEDZWIECKI, MD, PA
Entity type:Organization
Organization Name:COLLEEN NIEDZWIECKI, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEDZWIECKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-902-6116
Mailing Address - Street 1:4657 AYRON TER
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34685-4012
Mailing Address - Country:US
Mailing Address - Phone:727-902-6116
Mailing Address - Fax:
Practice Address - Street 1:2730 N MCMULLEN BOOTH RD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33761-3302
Practice Address - Country:US
Practice Address - Phone:727-791-7300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68554207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty