Basic Information
| Provider Information | |||||||||
| NPI: | 1427024520 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARKS | ||||||||
| FirstName: | GALEN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | RADIOLOGY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1115 2ND ST | ||||||||
| Address2: | |||||||||
| City: | FORT LUPTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806211745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038572771 | ||||||||
| FaxNumber: | 3038921511 | ||||||||
| Practice Location | |||||||||
| Address1: | 1115 2ND ST | ||||||||
| Address2: | |||||||||
| City: | FORT LUPTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806211745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3038572771 | ||||||||
| FaxNumber: | 3038921511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | 15862 | CO | Y | Allopathic & Osteopathic Physicians | Radiology | Body Imaging |
ID Information
| ID | Type | State | Issuer | Description | 01158625 | 05 | CO | MEDICAID |