Basic Information
Provider Information | |||||||||
NPI: | 1144547191 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ROCKY MOUNTAIN VEIN INSTITUTE PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 7702 | ||||||||
Address2: |   | ||||||||
City: | LOVELAND | ||||||||
State: | CO | ||||||||
PostalCode: | 805370702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9706632742 | ||||||||
FaxNumber: | 9703422093 | ||||||||
Practice Location | |||||||||
Address1: | 9441 HURON ST | ||||||||
Address2: |   | ||||||||
City: | THORNTON | ||||||||
State: | CO | ||||||||
PostalCode: | 802605426 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7194153092 | ||||||||
FaxNumber: | 7195466236 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/30/2010 | ||||||||
LastUpdateDate: | 11/18/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GIBBS | ||||||||
AuthorizedOfficialFirstName: | GORDON | ||||||||
AuthorizedOfficialMiddleName: | FABING | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/PROVIDER | ||||||||
AuthorizedOfficialTelephone: | 7195438346 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ROCKY MOUNTAIN VEIN INSTITUTE PLLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 11/18/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085U0001X | 45004 | CO | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0204X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.