Basic Information
| Provider Information | |||||||||
| NPI: | 1851341465 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARTY | ||||||||
| FirstName: | TERRI | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2121 E HARMONY RD | ||||||||
| Address2: | STE 330 | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805283400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702215878 | ||||||||
| FaxNumber: | 9702213564 | ||||||||
| Practice Location | |||||||||
| Address1: | 2121 E HARMONY RD | ||||||||
| Address2: | STE 330 | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805283400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702215878 | ||||||||
| FaxNumber: | 9702213564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 12/26/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 45632 | CO | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | P00801697 | 01 | CO | RAILROAD MEDICARE | OTHER | 48776742 | 05 | CO | MEDICAID | 870827400 | 05 | MN | MEDICAID |