Basic Information
Provider Information | |||||||||
NPI: | 1962473157 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COLEMAN | ||||||||
FirstName: | MICHELE | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KRATZER | ||||||||
OtherFirstName: | MICHELE | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2695 ROCKY MOUNTAIN AVE STE 150 | ||||||||
Address2: |   | ||||||||
City: | LOVELAND | ||||||||
State: | CO | ||||||||
PostalCode: | 805389071 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9706242420 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5818 N NEVADA AVE STE 200 | ||||||||
Address2: |   | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809183505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195990444 | ||||||||
FaxNumber: | 7193657150 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/27/2006 | ||||||||
LastUpdateDate: | 07/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/20/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 48751 | CO | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 35. 070982 | OH | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 2092702 | 05 | OH |   | MEDICAID | 43633340 | 05 | CO |   | MEDICAID |