Basic Information
| Provider Information | |||||||||
| NPI: | 1093123481 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEDIATRIC URGENT CARE OF NORTHERN COLORADO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 E ELIZABETH ST | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805244007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702679510 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4845 WEITZEL ST | ||||||||
| Address2: | |||||||||
| City: | TIMNATH | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805474800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026795109 | ||||||||
| FaxNumber: | 9702079967 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2014 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | FRED | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 9702679510 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FORT COLLINS YOUTH CLINIC | ||||||||
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| NPICertificationDate: | 04/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.