Basic Information
| Provider Information | |||||||||
| NPI: | 1124199682 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FITZGERALD | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9777 S YOSEMITE ST | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | LONE TREE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801243191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036997325 | ||||||||
| FaxNumber: | 3036995486 | ||||||||
| Practice Location | |||||||||
| Address1: | 9777 S YOSEMITE ST | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | LONE TREE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801243191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036997325 | ||||||||
| FaxNumber: | 3036995486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 10/14/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 45113 | CO | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 57272743 | 05 | CO | MEDICAID |