Basic Information
| Provider Information | |||||||||
| NPI: | 1962475194 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GARYFALLOU | ||||||||
| FirstName: | GARYFALLOS | ||||||||
| MiddleName: | T | ||||||||
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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: | 11600 W 2ND PL | ||||||||
| Address2: | ST. ANTHONY HOSPITAL, EMERGENCY DEPT. | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802281527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7203214161 | ||||||||
| FaxNumber: | 7203214165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| 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 | 35106 | CO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01351063 | 05 | CO | MEDICAID | 122686000 | 05 | WY | MEDICAID | 143822 | 05 | AZ | MEDICAID | 200401010A | 05 | KS | MEDICAID | P00335104 | 01 | CO | RR MEDICARE | OTHER | Z3286 | 05 | UT | MEDICAID |