Basic Information
| Provider Information | |||||||||
| NPI: | 1205812104 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MONTICELLI | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7951 E MAPLEWOOD AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD VILLAGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801114726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039307800 | ||||||||
| FaxNumber: | 3039307860 | ||||||||
| Practice Location | |||||||||
| Address1: | 2312 N NEVADA AVE STE 400 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809075320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195772555 | ||||||||
| FaxNumber: | 7195772553 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 01/27/2016 | ||||||||
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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 | 207RH0003X | MD21314 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | 0035987 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 158923 | 05 | OR | MEDICAID |