Basic Information
| Provider Information | |||||||||
| NPI: | 1730124835 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FRONT RANGE GASTROENTEROLOGY ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 S MAIN ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LONGMONT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805011716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037766115 | ||||||||
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| Practice Location | |||||||||
| Address1: | 205 S MAIN ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LONGMONT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805011716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037766115 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 07/24/2017 | ||||||||
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| AuthorizedOfficialLastName: | ZAVALA | ||||||||
| AuthorizedOfficialFirstName: | SARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3037766115 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 04015855 | 05 | CO | MEDICAID |