Basic Information
| Provider Information | |||||||||
| NPI: | 1295789824 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIAN HOUSECALLS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10900 W 44TH AVE UNIT 200 | ||||||||
| Address2: | |||||||||
| City: | WHEAT RIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800332742 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 10900 W 44TH AVE UNIT 200 | ||||||||
| Address2: | |||||||||
| City: | WHEAT RIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039931330 | ||||||||
| FaxNumber: | 3039575757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 05/07/2019 | ||||||||
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| AuthorizedOfficialLastName: | LALLY | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3039931330 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 42277531 | 05 | CO | MEDICAID | DE1013 | 01 | CO | RR MEDICARE PTAN | OTHER |