Provider Demographics
NPI:1376525733
Name:HAILEY, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:HAILEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1627 E 18TH ST
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-4209
Mailing Address - Country:US
Mailing Address - Phone:970-663-0135
Mailing Address - Fax:970-461-1422
Practice Address - Street 1:914 W 6TH ST
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537-5341
Practice Address - Country:US
Practice Address - Phone:970-667-3976
Practice Address - Fax:970-667-8177
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO24221207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD409COMedicaid
CO01242213Medicaid
COHA65754OtherANTHEM BCBS
AKMD409COMedicaid
CO01242213Medicaid
AKMD409COMedicaid
CO080068122Medicare PIN