Provider Demographics
NPI:1548474240
Name:COLGROVE, MICHAEL WALLACE (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:WALLACE
Last Name:COLGROVE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:11001 EXECUTIVE CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4393
Mailing Address - Country:US
Mailing Address - Phone:479-709-7490
Mailing Address - Fax:479-709-7495
Practice Address - Street 1:1500 DODSON AVE STE 230
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-5179
Practice Address - Country:US
Practice Address - Phone:479-709-7490
Practice Address - Fax:479-709-7495
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2024-07-16
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Provider Licenses
StateLicense IDTaxonomies
ARE8309207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR201771001Medicaid
AR201771001Medicaid
AR201771001Medicaid