Provider Demographics
NPI:1275953689
Name:KALLGREN DERMATOLOGY
Entity Type:Organization
Organization Name:KALLGREN DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PA-C
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:RANCIS
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:303-444-8100
Mailing Address - Street 1:3434 47TH STREET
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301
Mailing Address - Country:US
Mailing Address - Phone:303-444-8100
Mailing Address - Fax:303-444-8113
Practice Address - Street 1:3434 47TH STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301
Practice Address - Country:US
Practice Address - Phone:303-444-8100
Practice Address - Fax:303-444-8113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-24
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO179207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO562886Medicare UPIN