Basic Information
| Provider Information | |||||||||
| NPI: | 1093030033 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HATHCOCK | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2637 MIDPOINT DR STE B | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805254408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704881666 | ||||||||
| FaxNumber: | 9704729381 | ||||||||
| Practice Location | |||||||||
| Address1: | 2637 MIDPOINT DR STE B | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805254408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704881666 | ||||||||
| FaxNumber: | 9704729381 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2010 | ||||||||
| LastUpdateDate: | 11/01/2019 | ||||||||
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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 | 207R00000X | DR.0056304 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | DR.0056304 | CO | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 2146777 | 05 | LA | MEDICAID | 08187553 | 05 | MS | MEDICAID |