Provider Demographics
NPI:1073704318
Name:COLORADO UROLOGY CENTER PC
Entity Type:Organization
Organization Name:COLORADO UROLOGY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:IAN
Authorized Official - Middle Name:NORMAN
Authorized Official - Last Name:FAUCONIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-542-0444
Mailing Address - Street 1:PO BOX 218
Mailing Address - Street 2:
Mailing Address - City:FORT MORGAN
Mailing Address - State:CO
Mailing Address - Zip Code:80701-0218
Mailing Address - Country:US
Mailing Address - Phone:970-542-0444
Mailing Address - Fax:970-542-0111
Practice Address - Street 1:400 STATE ST
Practice Address - Street 2:
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701-2120
Practice Address - Country:US
Practice Address - Phone:970-542-0444
Practice Address - Fax:970-542-0111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO56178239Medicaid
COH05430Medicare UPIN
CO56178239Medicaid