Basic Information
| Provider Information | |||||||||
| NPI: | 1548352149 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FORT COLLINS FAMILY PHYSICIANS PROFESSIONAL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2121 E HARMONY RD | ||||||||
| Address2: | STE 370 | ||||||||
| City: | FT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805283404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702212290 | ||||||||
| FaxNumber: | 9702950036 | ||||||||
| Practice Location | |||||||||
| Address1: | 2121 E HARMONY RD | ||||||||
| Address2: | STE 370 | ||||||||
| City: | FT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805283404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702212290 | ||||||||
| FaxNumber: | 9702950036 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 01/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | SERRANO-TOY | ||||||||
| AuthorizedOfficialFirstName: | MONICA | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9702212290 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04118048 | 05 | CO | MEDICAID |