Provider Demographics
NPI:1184045726
Name:FRASER PROFESSIONAL MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:FRASER PROFESSIONAL MEDICAL GROUP LLC
Other - Org Name:FLYING HORSE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AARON
Authorized Official - Middle Name:S
Authorized Official - Last Name:FRASER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:719-433-5255
Mailing Address - Street 1:1615 SILVERSMITH RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-7225
Mailing Address - Country:US
Mailing Address - Phone:719-633-5255
Mailing Address - Fax:719-488-6753
Practice Address - Street 1:1615 SILVERSMITH RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80921-7225
Practice Address - Country:US
Practice Address - Phone:719-433-5255
Practice Address - Fax:719-488-6753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-28
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO50395207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
348752Medicare UPIN