Basic Information
| Provider Information | |||||||||
| NPI: | 1508861832 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENGLERT | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | LEE | ||||||||
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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: | 1900 BOISE AVE | ||||||||
| Address2: | STE 410 | ||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805385004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706672009 | ||||||||
| FaxNumber: | 9706672103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2005 | ||||||||
| LastUpdateDate: | 03/14/2008 | ||||||||
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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 | 174400000X | 20740 | CO | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 01207406 | 05 | CO | MEDICAID | 04011672 | 05 | CO | MEDICAID |