Basic Information
| Provider Information | |||||||||
| NPI: | 1508849514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALLAHAN | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | |||||||||
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| OtherLastName: | HALLAHAN | ||||||||
| OtherFirstName: | TARA | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 912215 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802912215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033067783 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Practice Location | |||||||||
| Address1: | 1024 S LEMAY AVE | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805243929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033067783 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 05/13/2014 | ||||||||
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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 | 207P00000X | 5101014849 | MI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 44750 | CO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 80550070 | 05 | CO | MEDICAID | S5008 | 01 | BCBS | OTHER | P00371081 | 01 | RAILROAD MEDICARE | OTHER | 125166000 | 05 | WY | MEDICAID |