Basic Information
| Provider Information | |||||||||
| NPI: | 1811156656 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GERVAIS | ||||||||
| FirstName: | JACK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5788 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802175788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032021280 | ||||||||
| FaxNumber: | 3032021281 | ||||||||
| Practice Location | |||||||||
| Address1: | 340 PEAK ONE DR. | ||||||||
| Address2: | |||||||||
| City: | FRISCO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804430738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706688123 | ||||||||
| FaxNumber: | 9706682844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2008 | ||||||||
| LastUpdateDate: | 08/14/2013 | ||||||||
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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 | 207P00000X | 50036 | CO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 816363 | 05 | AZ | MEDICAID | 20326023101 | 01 | PACIFICARE SECURE HORIZONS | OTHER | 73872369 | 05 | CO | MEDICAID | P00980274 | 01 | RR MEDICARE | OTHER |