Basic Information
| Provider Information | |||||||||
| NPI: | 1265624811 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORSON | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | JACOB | ||||||||
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| OtherLastName: | CORSON | ||||||||
| OtherFirstName: | THOMAS | ||||||||
| OtherMiddleName: | JACOB | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 173817 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802173817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033067783 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 BOISE AVE | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805385006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706354071 | ||||||||
| FaxNumber: | 9706354177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2007 | ||||||||
| LastUpdateDate: | 03/13/2018 | ||||||||
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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 | 047701 | CT | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | 48063 | CO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 86452550 | 05 | CO | MEDICAID | 021193 | 01 | CO | KAISER COMMERCIAL NUMBER | OTHER |