Basic Information
| Provider Information | |||||||||
| NPI: | 1447325097 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FRONT RANGE PSYCHIATRIC ASSOCIATES, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 56 CLUB MANOR DR | ||||||||
| Address2: | 100 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810081679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195844767 | ||||||||
| FaxNumber: | 7195844808 | ||||||||
| Practice Location | |||||||||
| Address1: | 56 CLUB MANOR DR | ||||||||
| Address2: | 100 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810081679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195844767 | ||||||||
| FaxNumber: | 7195844808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 09/27/2013 | ||||||||
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| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | DANA | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7195844767 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 56826338 | 05 | CO | MEDICAID |