Basic Information
| Provider Information | |||||||||
| NPI: | 1235126582 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAILEY | ||||||||
| FirstName: | JIMMIE | ||||||||
| MiddleName: | DALE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 E JOHNSON ST | ||||||||
| Address2: | |||||||||
| City: | HOLYOKE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 807341854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708542500 | ||||||||
| FaxNumber: | 9708543887 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 E JOHNSON ST | ||||||||
| Address2: | |||||||||
| City: | HOLYOKE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 807341854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708542500 | ||||||||
| FaxNumber: | 9708543887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 06/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD. 22758 | AL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | DR.0065419 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME 125949 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | DR.0065419 | 01 | CO | CO LICENSE NUMBER | OTHER | 9000188171 | 05 | CO | MEDICAID |