Basic Information
| Provider Information | |||||||||
| NPI: | 1740462167 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LARS A. STANGEBYE, MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 816 S 5TH ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814015765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702404311 | ||||||||
| FaxNumber: | 9702407976 | ||||||||
| Practice Location | |||||||||
| Address1: | 816 S 5TH ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814015765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702404311 | ||||||||
| FaxNumber: | 9702407976 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | STANGEBYE | ||||||||
| AuthorizedOfficialFirstName: | LARS | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE PROPRIETOR | ||||||||
| AuthorizedOfficialTelephone: | 9702404311 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 65734751 | 05 | CO | MEDICAID |