Provider Demographics
NPI:1043382401
Name:ALEXANDRA THERIAULT, MD, PC
Entity Type:Organization
Organization Name:ALEXANDRA THERIAULT, MD, PC
Other - Org Name:APEX DERMATOLOGY GROUP PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:THERIOULT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-795-2030
Mailing Address - Street 1:1420 W CANAL CT
Mailing Address - Street 2:#50
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80120-5655
Mailing Address - Country:US
Mailing Address - Phone:303-795-2030
Mailing Address - Fax:303-795-2153
Practice Address - Street 1:1420 W CANAL CT
Practice Address - Street 2:#50
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80120-5655
Practice Address - Country:US
Practice Address - Phone:303-795-2030
Practice Address - Fax:303-795-2153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC446718Medicare PIN