Basic Information
| Provider Information | |||||||||
| NPI: | 1184696411 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERSZT | ||||||||
| FirstName: | SAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 535 16TH ST | ||||||||
| Address2: | STE 750 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802024228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038254646 | ||||||||
| FaxNumber: | 3038253215 | ||||||||
| Practice Location | |||||||||
| Address1: | 535 16TH ST | ||||||||
| Address2: | STE 750 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802024228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038254646 | ||||||||
| FaxNumber: | 3038253215 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 03/27/2012 | ||||||||
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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 | 207R00000X | 36953 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 22928243 | 05 | CO | MEDICAID |