Provider Demographics
NPI:1396231627
Name:ALTITUDE SURGERY CENTER LONE TREE PLLC
Entity Type:Organization
Organization Name:ALTITUDE SURGERY CENTER LONE TREE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:FANGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:720-328-4990
Mailing Address - Street 1:10375 PARK MEADOWS DR STE 150B
Mailing Address - Street 2:
Mailing Address - City:LONE TREE
Mailing Address - State:CO
Mailing Address - Zip Code:80124-6735
Mailing Address - Country:US
Mailing Address - Phone:720-328-4990
Mailing Address - Fax:720-328-4994
Practice Address - Street 1:10375 PARK MEADOWS DR STE 150B
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-6735
Practice Address - Country:US
Practice Address - Phone:720-328-4990
Practice Address - Fax:720-328-4994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1770091720OtherGROUP NPI ROBINSON AND FANGMAN COSMETIC SURGERY LONE TREE, PLLC
NY1609027556OtherINDIVIDUAL NPI
CO1952791964Medicaid