Basic Information
| Provider Information | |||||||||
| NPI: | 1598799314 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HURST | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | GORDON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 337420 | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806330624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706632742 | ||||||||
| FaxNumber: | 9706670847 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 16TH ST | ||||||||
| Address2: | |||||||||
| City: | GREELEY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806315154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706799349 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 12/14/2010 | ||||||||
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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 | 22264 | CO | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 930005396 | 01 | CO | RAILROAD MEDICARE | OTHER | 01222645 | 05 | CO | MEDICAID |