Basic Information
| Provider Information | |||||||||
| NPI: | 1295821403 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DRISCOLL | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | BARBARA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5881 W 16TH ST | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806342910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703132700 | ||||||||
| FaxNumber: | 9703132727 | ||||||||
| Practice Location | |||||||||
| Address1: | 5881 W 16TH ST | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806342910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703132700 | ||||||||
| FaxNumber: | 9703132727 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 07/01/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 35078997 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 01054599 | IN | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 47812 | CO | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 78126754 | 05 | CO | MEDICAID | P00944870 | 01 | CO | MEDICARE RAILROAD CARRIER PTAN | OTHER | 200339730 | 05 | IN | MEDICAID | 2277763 | 05 | OH | MEDICAID |