Provider Demographics
NPI:1558853846
Name:CROSSROADS DERMATOLOGY LLC
Entity Type:Organization
Organization Name:CROSSROADS DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BAIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-504-6273
Mailing Address - Street 1:1610 TURIN DR
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80503-2717
Mailing Address - Country:US
Mailing Address - Phone:813-504-6273
Mailing Address - Fax:
Practice Address - Street 1:2350 17TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-1738
Practice Address - Country:US
Practice Address - Phone:720-204-3376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-01
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO48408207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1760670863OtherINDIVIDUAL NPI - SARAH M BAIR
CO04440087Medicaid