Basic Information
| Provider Information | |||||||||
| NPI: | 1861499428 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RALEY | ||||||||
| FirstName: | JANICE | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 175 S UNION BLVD | ||||||||
| Address2: | STE 220 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809103147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196341532 | ||||||||
| FaxNumber: | 7196341715 | ||||||||
| Practice Location | |||||||||
| Address1: | 175 S UNION BLVD | ||||||||
| Address2: | STE 220 | ||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809103147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196341532 | ||||||||
| FaxNumber: | 7196341715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2005 | ||||||||
| LastUpdateDate: | 12/12/2013 | ||||||||
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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 | 207V00000X | 42336 | CO | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 37503561 | 05 | CO | MEDICAID |