Basic Information
| Provider Information | |||||||||
| NPI: | 1235116328 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONAHAN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JEROME | ||||||||
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| OtherLastName: | MONAHAN | ||||||||
| OtherFirstName: | MICHAEL | ||||||||
| OtherMiddleName: | J | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1175 | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801501175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033067783 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 E JOHNSON ST | ||||||||
| Address2: | |||||||||
| City: | HOLYOKE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 807341854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708542241 | ||||||||
| FaxNumber: | 9704584581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | DR.0022502 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 22502 | CO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 930080436 | 01 | CO | PAILROAD MEDICARE PIN | OTHER | 01225028 | 05 | CO | MEDICAID |