Basic Information
| Provider Information | |||||||||
| NPI: | 1831295070 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SICKBERT | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., L.L.C. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SICKBERT | ||||||||
| OtherFirstName: | SCOTT | ||||||||
| OtherMiddleName: | F | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D., L.L.C. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5920 MCINTYRE ST | ||||||||
| Address2: | |||||||||
| City: | GOLDEN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804037445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7204344876 | ||||||||
| FaxNumber: | 3032254246 | ||||||||
| Practice Location | |||||||||
| Address1: | 5920 MCINTYRE ST | ||||||||
| Address2: | |||||||||
| City: | GOLDEN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804037445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7204344876 | ||||||||
| FaxNumber: | 3032254246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 02/13/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | DR.0025001 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | 25001 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 68902573 | 05 | CO | MEDICAID |