Basic Information
| Provider Information | |||||||||
| NPI: | 1235119553 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLEISTEIN | ||||||||
| FirstName: | ABBY | ||||||||
| MiddleName: | LISE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 ELDORADO BLVD STE 6250 | ||||||||
| Address2: | |||||||||
| City: | BROOMFIELD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800213421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3032720768 | ||||||||
| FaxNumber: | 3033182488 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 CAMPUS DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800263357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036731900 | ||||||||
| FaxNumber: | 3036731915 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 12/18/2013 | ||||||||
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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 | 207R00000X | 39420 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 39420 | CO | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | P00773004 | 01 | CO | MEDICARE RAILROAD | OTHER | 43753311 | 05 | CO | MEDICAID |