Basic Information
| Provider Information | |||||||||
| NPI: | 1831315662 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHERN COLORADO HOSPITALISTS PROFESSIONAL LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTHERN COLORADO HOSPITALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2637 MIDPOINT DR STE F | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805254432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704881666 | ||||||||
| FaxNumber: | 9704729381 | ||||||||
| Practice Location | |||||||||
| Address1: | 2637 MIDPOINT DR STE F | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805254432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704881666 | ||||||||
| FaxNumber: | 9704729381 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 03/25/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HATHCOCK | ||||||||
| AuthorizedOfficialFirstName: | ALAN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9704881666 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 72856548 | 05 | CO | MEDICAID | 10025520600 | 05 | NE | MEDICAID | DG2538 | 01 | CO | RAILROAD MEDICARE | OTHER |