Basic Information
Provider Information | |||||||||
NPI: | 1225239148 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HORNER | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | NEIL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 660 GOLDEN RIDGE RD | ||||||||
Address2: | STE. 250 | ||||||||
City: | GOLDEN | ||||||||
State: | CO | ||||||||
PostalCode: | 804019541 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3032331223 | ||||||||
FaxNumber: | 3032338755 | ||||||||
Practice Location | |||||||||
Address1: | 660 GOLDEN RIDGE RD | ||||||||
Address2: | STE. 250 | ||||||||
City: | GOLDEN | ||||||||
State: | CO | ||||||||
PostalCode: | 804019541 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3032331223 | ||||||||
FaxNumber: | 3032338755 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/29/2007 | ||||||||
LastUpdateDate: | 02/14/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 5101017183 | MI | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 208100000X | 52882 | CO | Y |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
ID Information
ID | Type | State | Issuer | Description | 1225239148 | 05 | MI |   | MEDICAID | 43070388 | 05 | CO |   | MEDICAID |