Basic Information
| Provider Information | |||||||||
| NPI: | 1538233234 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FRONT RANGE EMERGENCY SPECIALISTS, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 N NEVADA AVE | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809076819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194750299 | ||||||||
| FaxNumber: | 7194750414 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 N NEVADA AVE | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809076819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194750299 | ||||||||
| FaxNumber: | 7194750414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 09/09/2010 | ||||||||
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| AuthorizedOfficialLastName: | GALLEGOS | ||||||||
| AuthorizedOfficialFirstName: | RUBY | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7194750299 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01218742 | 05 | CO | MEDICAID |