Provider Demographics
NPI:1508078759
Name:HALLIWELL, BROOKE M (DO)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:M
Last Name:HALLIWELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:M
Other - Last Name:BENGTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1830 BLAKE AVENUE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:GLENWOOD SPGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-4592
Mailing Address - Country:US
Mailing Address - Phone:970-945-2238
Mailing Address - Fax:970-928-8926
Practice Address - Street 1:1830 BLAKE AVENUE
Practice Address - Street 2:SUITE 208
Practice Address - City:GLENWOOD SPGS
Practice Address - State:CO
Practice Address - Zip Code:81601-4592
Practice Address - Country:US
Practice Address - Phone:970-945-2238
Practice Address - Fax:970-928-8926
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT012106207V00000X
CO49947207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO49947OtherLICENSE
1508078759OtherNPI
CO61273546Medicaid
855IMedicare PIN