Basic Information
| Provider Information | |||||||||
| NPI: | 1376525733 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAILEY | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1627 E 18TH ST | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805384209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706630135 | ||||||||
| FaxNumber: | 9704611422 | ||||||||
| Practice Location | |||||||||
| Address1: | 914 W 6TH ST | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805375341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706673976 | ||||||||
| FaxNumber: | 9706678177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2005 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 24221 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD409CO | 05 | AK | MEDICAID | 01242213 | 05 | CO | MEDICAID | HA65754 | 01 | CO | ANTHEM BCBS | OTHER |